Menstrual disorder

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Menstrual Cycle including Menstrual phase (often referred to as "period") Lining of Uterine Wall.jpg
Menstrual Cycle including Menstrual phase (often referred to as "period")

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. [1] Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability. [2] [3]

Contents

Though menstrual disorders were once considered more of a nuisance problem, they are now widely recognized as having a serious impact on society in the form of days lost from work brought about by the pain and suffering experienced by women. These disorders can arise from physiologic sources (pregnancy etc.), pathologic sources (stress, excessive exercise, weight loss, endocrine or structural abnormalities etc.), or iatrogenic sources (secondary to contraceptive use etc.). [4]

Types of menstrual disorders

Premenstrual Disorders

Disorders of cycle length

Normal menstrual cycle length is 22–45 days. [4]

Disorders of flow

Normal menstrual flow length is 3–7 days. [4]

Disorders of ovulation

Disorders of ovulation include oligoovulation and anovulation: [14]

Other menstrual disorders

Signs and symptoms of menstrual disorders

Diagram of a uterus 3D Medical Animation Uterus.jpg
Diagram of a uterus

The signs and symptoms of menstrual disorders can cause significant stress. Abnormal uterine bleeding (AUB) has the potential to be one of the most urgent gynecological problems during menstruation. Dysmenorrhea is the most common. [2]

Premenstrual Syndrome (PMS)

Symptoms may include irritability, bloating, depression, food cravings, aggressiveness, and mood swings. Fluid retention and fluctuating weight gain are also reported. [4]

Precipitating risk factors include: stress, alcohol consumption, exercise, smoking, and some medications. [4]

Amenorrhea

Lack of a menses by the age of 16 where secondary sexual characteristics have developed or by the age of 14 where no secondary sexual characteristics have developed (primary amenorrhea), or lack of a menses for more than 3–6 months after first menstruation cycle. [2] Although missing a period is the main sign, other symptoms can include: excess facial, hair loss, headache, changes to vision, milky discharge from the breasts, or absence of breast development. [18]

Abnormal Uterine Bleeding

One-third of women will experience abnormal uterine bleeding in their life. Normal menstrual cycle has a frequency of 24 to 38 days, lasts 7 to 9 days, so bleeding that lasts longer could be considered abnormal. Very heavy bleeding (for example, needing to use 1 or more tampons or sanitary pads every hour) is another symptom. [19]

Dysmenorrhea

Especially painful or persistent menstrual cramping that occurs in the absence of any underlying pelvic disease. [4]

Pain radiating to the low back or upper thighs with onset of menstruation and lasting anywhere from 12 to 72 hours. Headache, nausea, vomiting, diarrhea, and fatigue may also accompany the pain. Pain may begin gradually, with the first several years of menses, and then intensified as menstruation becomes regular. Patients who also have secondary amenorrhea report symptoms beginning after age 20 and lasting 5–7 days with progressive worsening of pain over time. Pelvic pain is also reported. [4]

Causes of menstrual disorders

There are many causes of menstrual disorders, including uterine fibroids, hormonal imbalances, clotting disorders, cancer, sexually-transmitted infections, polycystic ovary syndrome, and genetics. [20] Uterine fibroids are benign, non-cancerous growths in the uterus that affect most women at some point in their lives and usually does not require treatment unless they cause intolerable symptoms. [21] Stress and lifestyle factors commonly impact menstruation, which includes weight changes, dieting, changes in exercise, travel, and illness. [22]

Hyperprolactinaemia can also cause menstrual disorders.

Amenorrhea

There are different causes depending on the type of menstrual(period) disorder. Amenorrhea, or the absence of menstruation, is subdivided into primary and secondary amenorrhea. In primary amenorrhea, in which there is a failure to menstruate by the age of 16 with normal sexual development or by 14 without normal sexual development, causes can be from developmental abnormalities of the uterus, ovaries, or genital tract, or endocrine disorders. In secondary amenorrhea, or the absence of menstruation for greater than 6 months, can be caused by the same reasons as primary amenorrhea, as well as polycystic ovary syndrome, pregnancy, chronic illness, and certain drugs like cocaine and opioids. [23]

Hypomenorrhea

Causes of hypomenorrhea, or irregular light periods, include periods around menopause, eating disorders, excessive exercise, thyroid dysfunction, uncontrolled diabetes, Cushing's syndrome, hormonal birth control, and certain medications to treat epilepsy or mental health conditions. [24]

Menorrhagia

Causes of menorrhagia, or heavy menstrual bleeding, include polycystic ovary syndrome, uterine fibroids, endometrial polyps, bleeding disorders, and miscarriage. [24]

Dysmenorrhea

Causes of dysmenorrhea, or menstrual pain, include endometriosis, pelvic scarring due to chlamydia or gonorrhea, and intrauterine devices or IUDs. [24] Primary dysmenorrhea is when there is no underlying cause that is identified, and secondary dysmenorrhea is when the menstrual pain is caused by other conditions such as endometriosis, fibroids, or infection. [25]

Diagnosis of menstrual disorders

Pelvic exam Pelvic exam nci-vol-1786-300.jpg
Pelvic exam

Diagnosis begins with an in-depth medical history and physical exam, including a pelvic exam and sometimes a Pap smear. [26]

Additional testing may include but are not limited to blood tests, hormonal tests, ultrasound, gynecologic ultrasound, magnetic resonance imaging (MRI), hysteroscopy, laparoscopy, endometrial biopsy, and dilation and curettage (D&C). [26]

Treatment of menstrual disorders

Premenstrual syndrome and premenstrual dysphoric disorder

Due to the unclear etiology of premenstrual syndrome and premenstrual dysphoric disorder, symptom relief is the primary goal of treatment. Selective serotonin reuptake inhibitors and spironolactone decrease physical and psychological symptoms associated with premenstrual syndrome. Oral contraceptives may ameliorate physical symptoms of breast tenderness and bloating. Ovarian suppression treatment with gonadotropin-releasing hormone agonist as an off-label use may reduce symptoms but have adverse side effects including decreased bone density. Other less commonly use medications such as alprazolam may reduce anxiety symptoms but has potential for dependence, tolerance, and abuse. Pyridoxine, a form of vitamin B6, may be used as a dietary supplement to relieve overall symptoms. [27] [28] [29]

Amenorrhea

Successful treatment varies depending on the diagnosis of amenorrhea. In patients with functional hypothalamic amenorrhea due to physical or psychological stress, non-pharmacological options include weight gain, resolution of emotional issues, or decreased intensity of exercise. Patients experiencing amenorrhea due to hypothyroidism may be started with thyroid replacement therapy. Dopamine agonists such as bromocriptine are used in patients with pituitary adenomas. Amenorrhea associated with gonadal dysgenesis or a hypoestrogenic state may be treated with oral contraceptives, patches, or vaginal rings. [4]

Amenorrhea associated with structural anomalies can be addressed with surgical treatment such as gonadectomy. [30]

Menorrhagia

Acute management of menstrual bleeding includes hormonal therapy with estrogen or oral contraceptives until bleeding has stopped followed by an oral contraceptive tapering regimen. Adjunctive therapy may include iron supplements and nonsteroidal anti-inflammatory drugs. [31] Patients who do not respond to hormonal therapy may use antifibrinolytics. Procedural therapy such as a suction curettage and intrauterine balloon tamponade are reserved for patients who do not respond to medication therapy and do not put fertility at risk. Life-threatening situations may consider more invasive procedures such as endometrial ablation, uterine artery embolization, and hysterectomy. [32]

Long-term management include estrogen-containing therapy and progestin therapy. [33]

Dysmenorrhea

Primary dysmenorrhea is commonly treated with nonsteroidal anti-inflammatory drugs such as ibuprofen to reduce moderate to severe pain. Other simple analgesics such as aspirin or acetaminophen are less commonly used but may also reduce short-term pain. Supplements including thiamine and vitamin E may reduce pain in younger women. Non-pharmacological interventions such as the use of external heat are also effective at reducing pain. [34] Regular exercises can also reduce pain. [35]

See also

Related Research Articles

<span class="mw-page-title-main">Menstruation</span> Shedding of the uterine lining

Menstruation is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. The menstrual cycle is characterized by the rise and fall of hormones. Menstruation is triggered by falling progesterone levels and is a sign that pregnancy has not occurred.

<span class="mw-page-title-main">Menstrual cycle</span> Natural changes in the human female reproductive system

The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that makes pregnancy possible. The ovarian cycle controls the production and release of eggs and the cyclic release of estrogen and progesterone. The uterine cycle governs the preparation and maintenance of the lining of the uterus (womb) to receive an embryo. These cycles are concurrent and coordinated, normally last between 21 and 35 days, with a median length of 28 days. Menarche usually occurs around the age of 12 years; menstrual cycles continue for about 30–45 years.

<span class="mw-page-title-main">Ovulation</span> Release of egg cells from the ovaries

Ovulation is the release of eggs from the ovaries. In women, this event occurs when the ovarian follicles rupture and release the secondary oocyte ovarian cells. After ovulation, during the luteal phase, the egg will be available to be fertilized by sperm. In addition, the uterine lining (endometrium) is thickened to be able to receive a fertilized egg. If no conception occurs, the uterine lining as well as the egg will be shed during menstruation.

Premenstrual syndrome (PMS) is a disruptive set of emotional and physical symptoms that regularly occur in the one to two weeks before the start of each menstrual period. Symptoms resolve around the time menstrual bleeding begins. Different women experience different symptoms. Premenstrual syndrome commonly produces one or more physical, emotional, or behavioral symptoms, that resolve with menses. The range of symptoms is wide, and most commonly are breast tenderness, bloating, headache, mood swings, depression, anxiety, anger, and irritability. To be diagnosed as PMS, rather than a normal discomfort of the menstrual cycle, these symptoms must interfere with daily living, during two menstrual cycles of prospective recording. These symptoms are nonspecific and are seen in women without PMS. Often PMS-related symptoms are present for about six days. An individual's pattern of symptoms may change over time. PMS does not produce symptoms during pregnancy or following menopause.

Amenorrhea or amenorrhoea is the absence of a menstrual period in a female who has reached reproductive age. Physiological states of amenorrhoea are seen, most commonly, during pregnancy and lactation (breastfeeding). Outside the reproductive years, there is absence of menses during childhood and after menopause.

<span class="mw-page-title-main">Dysmenorrhea</span> Pain during and sometimes before menstruation

Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the pelvis or lower abdomen. Other symptoms may include back pain, diarrhea or nausea.

Premenstrual dysphoric disorder (PMDD) is a mood disorder characterized by emotional, cognitive, and physical symptoms. PMDD causes significant distress or impairment in menstruating women during the luteal phase of the menstrual cycle. The symptoms occur in the luteal phase, improve within a few days after the onset of menses, and are minimal or absent in the week after menses. PMDD has a profound impact on a woman’s quality of life and dramatically increases the risk of suicidal ideation and even suicide attempts. Many women of reproductive age experience discomfort or mild mood changes prior to menstruation. However, 5–8% experience severe premenstrual syndrome causing significant distress or functional impairment. Within this population of reproductive age, some will meet the criteria for PMDD.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

Anovulation is when the ovaries do not release an oocyte during a menstrual cycle. Therefore, ovulation does not take place. However, a woman who does not ovulate at each menstrual cycle is not necessarily going through menopause. Chronic anovulation is a common cause of infertility.

Abnormal uterine bleeding (AUB), also known as atypical vaginal bleeding (AVB), is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term dysfunctional uterine bleeding was used when no underlying cause was present. Vaginal bleeding during pregnancy is excluded. Iron deficiency anemia may occur and quality of life may be negatively affected.

An anovulatory cycle is a menstrual cycle characterised by the absence of ovulation and a luteal phase. It may also vary in duration from a regular menstrual cycle.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Intermenstrual bleeding (IMB) is vaginal bleeding at irregular intervals between expected menstrual periods. It may be associated with bleeding with sexual intercourse.

Polymenorrhea, also known as frequent periods, frequent menstruation, or frequent menstrual bleeding, is a menstrual disorder in which menstrual cycles are shorter than 21 days in length and hence where menstruation occurs more frequently than usual. Cycles are regular and menstrual flow is normal in the condition. Normally, menstrual cycles are 25 to 30 days in length, with a median duration of 28 days.

Functional hypothalamic amenorrhea (FHA) is a form of amenorrhea and chronic anovulation and is one of the most common types of secondary amenorrhea. It is classified as hypogonadotropic hypogonadism. It was previously known as "juvenile hypothalamosis syndrome," prior to the discovery that sexually mature females are equally affected. FHA has multiple risk factors, with links to stress-related, weight-related, and exercise-related factors. FHA is caused by stress-induced suppression of the hypothalamic-pituitary-ovarian (HPO) axis, which results in inhibition of gonadotropin-releasing hormone (GnRH) secretion, and gonadotropins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Severe and potentially prolonged hypoestrogenism is perhaps the most dangerous hormonal pathology associated with the disease, because consequences of this disturbance can influence bone health, cardiovascular health, mental health, and metabolic functioning in both the short and long-term. Because many of the symptoms overlap with those of organic hypothalamic, pituitary, or gonadal disease and therefore must be ruled out, FHA is a diagnosis of exclusion; "functional" is used to indicate a behavioral cause, in which no anatomical or organic disease is identified, and is reversible with correction of the underlying cause. Diagnostic workup includes a detailed history and physical, laboratory studies, such as a pregnancy test, and serum levels of FSH and LH, prolactin, and thyroid-stimulating hormone (TSH), and imaging. Additional tests may be indicated in order to distinguish FHA from organic hypothalamic or pituitary disorders. Patients present with a broad range of symptoms related to severe hypoestrogenism as well as hypercortisolemia, low serum insulin levels, low serum insulin-like growth factor 1 (IGF-1), and low total triiodothyronine (T3). Treatment is primarily managing the primary cause of the FHA with behavioral modifications. While hormonal-based therapies are potential treatment to restore menses, weight gain and behavioral modifications can have an even more potent impact on reversing neuroendocrine abnormalities, preventing further bone loss, and re-establishing menses, making this the recommended line of treatment. If this fails to work, secondary treatment is aimed at treating the effects of hypoestrogenism, hypercortisolism, and hypothyroidism.

Hypomenorrhea or hypomenorrhoea, also known as short or scanty periods, is extremely light menstrual blood flow. It is the opposite of heavy periods or hypermenorrhea which is more properly called menorrhagia.

Estrogen dominance (ED) is a theory about a metabolic state where the level of estrogen outweighs the level of progesterone in the body. This is said to be caused by a decrease in progesterone without a subsequent decrease in estrogen.

Menstrual suppression refers to the practice of using hormonal management to stop or reduce menstrual bleeding. In contrast to surgical options for this purpose, such as hysterectomy or endometrial ablation, hormonal methods to manipulate menstruation are reversible.

Hormonal oral contraceptives are preventive medications taken orally to avoid pregnancy in sexually active active females by manipulating their sex hormones. The first oral contraceptive was approved by the FDA and sold to the market in 1960. There are two types of hormonal oral contraceptives, namely Combined Oral Contraceptives and Progesterone Only Pills. Oral contraceptives, be it combined or progesterone-only, can effectively prevent pregnancy by regulating hormonal changes in the menstrual cycle, inhibiting ovulation, and altering cervical mucus to impede sperm mobility; combined pills have extra effects in menstrual cycle regulation and menstrual pain relief. Common off-label uses include menstrual suppression and acne relief, with Combined Oral Contraceptives having additional benefits in relieving menstrual migraine.

References

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  21. ↑ "Uterine Fibroids". Baylor College of Medicine.
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