MENSTRUAL DISORDERS

AMENORRHEA, DYSMENORRHEA, MENORRHAGIA, METRORRHAGIA

WHAT IS MENSTRUAL DISORDERS?

Menstrual disorders are irregularities or abnormalities of the menstrual cycle. They include amenorrhea, dysmenorrhea, menorrhagia, and metrorrhagia. Amenorrhea is the absence of menstrual periods. Amenorrhea can be either primary or secondary. Primary amenorrhea is defined as the failure to start menstruating by the age of sixteen. The main cause of primary amenorrhea is a delay in the onset of puberty. Secondary amenorrhea refers to the temporary or permanent cessation of menstrual periods in a woman who has menstruated regularly in the past. The most common cause of secondary amenorrhea is pregnancy. Other causes include emotional stress, depression, obesity, excessive or rapid weight loss, reduced caloric intake, including self-starvation (anorexia nervosa), systemic diseases (syphilis, tuberculosis, nephritis), or drugs. It can also be caused by endocrine disorders or hormonal imbalances. Ovary disorders, such as cysts or a tumor, can cause secondary amenorrhea. Menstrual periods may cease temporarily after a woman stops taking birth control pills. Although this temporary amenorrhea usually only lasts six to eight weeks, it is possible to persist for a year or more. Permanent amenorrhea occurs after the menopause, or if a woman has her uterus surgically removed (hysterectomy). Dysmenorrhea refers to pain or discomfort during or just before a menstrual period. Beginning two or three years after the first menstrual period, dysmenorrhea may diminish after the age of 25 or after childbirth. Approximately 50% of menstruating women experience this disorder, and about ten percent of these are incapacitated for several days. Dysmenorrhea is classified as primary or secondary. Primary dysmenorrhea is known to be associated with the hormonal changes connected with the menstrual period, but the exact cause is uncertain. One theory is that dysmenorrhea is caused by the excessive production of (or the undue sensitivity to) the hormone prostaglandin that stimulates muscular contractions of the uterus. Primary dysmenorrhea is not a behavioral or psychological disorder. Secondary dysmenorrhea is caused by an underlying condition, such as using an IUD, endometriosis, pelvic inflammatory disease, or fibroid tumors in the uterus (uterine leiomyoma). Menorrhagia is the excessive loss of blood during a menstrual period. This blood loss can be excessive either due to the number of days (greater than seven days), the actual amount of blood lost (greater than 80 milliliters), or both. Menorrhagia is usually caused by an imbalance in the hormones that control menstruation (estrogen and progesterone), resulting in an excessive buildup of the lining of the uterus (endometrium). Menorrhagia can also be caused by any disorder that affects the uterus including fibroid tumors, polyps of the uterus, the presence of an intrauterine device (IUD) used for contraception, or a pelvic infection. Sometimes no physical cause can be found. Metrorrhagia is abnormal bleeding from the uterus that is different from the normal menstrual cycle pattern. Irregularities can occur in the interval between menstrual periods, the duration of the bleeding, or the amount of blood lost. Metrorrhagia can be caused by a hormonal imbalance, stress or travel, unsuspected pregnancy, early miscarriage, disorder of the uterus, ovaries, or pelvic cavity (such as

endometriosis), by lesions in the cervix or lining of the uterus (endometrium), or by a cancer (malignancy) in the genital tract.

HOW IS IT DIAGNOSED?
History: Amenorrhea (primary and secondary) is the absence of menstrual periods. Some causes may be ruled out through patient history. In dysmenorrhea, symptoms include cramping, labor-like pain in the lower abdomen that starts just prior to or at the time the menstrual period begins. Pain may come and go in waves. There may also be nausea, vomiting, and a dull, lower backache. Approximately ten percent of women have symptoms severe enough to interfere with their work or leisure activities. In secondary dysmenorrhea, pain begins several days before and lasts throughout the menstrual period. Dysmenorrhea can be preceded by premenstrual syndrome (bloating, irritability, and depression). Normally, a woman loses about two fluid ounces (60 milliliters) of blood during an average menstrual period. During menorrhagia, a woman may lose three ounces (90 milliliters) or more. Menorrhagia can be a regular occurrence or rare event. Metrorrhagia means a deviation from the normal menstrual pattern. Variations may include the intervals between periods, the duration of the bleeding, or the amount of blood lost. Physical exam: A pelvic exam is needed to rule out congenital abnormalities, pregnancy, and ovary disorders for amenorrhea. For dysmenorrhea, a bimanual pelvic exam (fingers of one hand in the vagina and the other hand presses on the abdomen) rules out uterine tenderness or enlarged ovaries. It is essential that secondary dysmenorrhea be distinguished from primary dysmenorrhea as the treatment is different for each. For menorrhagia and metrorrhagia, the rate of bleeding is assessed. Pelvic exam establishes uterine size and rules out cervical lesions or polyps. Tests: For amenorrhea, blood tests measure hormone levels. A laparoscopy (tiny microscope inserted into the abdomen) enables visual inspection of reproductive organs to detect abnormalities. CT scan or MRI of pituitary should be done if fasting prolactin is markedly elevated. Ultrasound scanning of abdomen and pelvis can rule out tumor of adrenal gland or ovary. Diagnostic tests for dysmenorrhea, menorrhagia, and metrorrhagia may include pregnancy test, Pap smear, urine and cervical cultures. An endometrial biopsy, ultrasound, or laparoscopy may be considered. Treatment of secondary dysmenorrhea depends on the cause, so it is essential that the underlying condition be accurately identified. Conditions that must be ruled out include endometriosis pelvic inflammatory disease, and fibroid tumors of the uterus. Other tests for menorrhagia and metrorrhagia may include a complete blood count (CBC) and endocrine testing to rule out underlying conditions. A transvaginal ultrasound may be done to assess endometrial thickness. A D&C (dilation and curettage) may be performed to investigate the cause of the bleeding.

HOW IS IT TREATED?
Treatment is focused on the cause of the disorder. Although treatment for primary or secondary amenorrhea may be optional, the cause should be identified. Underlying conditions need to be treated. An ovarian tumor requires surgical removal. An ovarian cyst may need to be biopsied or removed. If amenorrhea is the result of an endocrine imbalance, ovulation (and the resulting menstruation) can

usually be started again by treatment with a fertility drug used to stimulate ovulation or gonadotropin hormones. Weight problems, over-exercise, and anorexia nervosa need to be addressed due to the long-term threat to the woman's health. Treatment for primary dysmenorrhea includes pain relievers (analgesics) and drugs that block the action of prostaglandin (analgesics). Birth control pills (oral contraceptives) and other noncontraceptive hormones can relieve symptoms by suppressing ovulation. Treatment of secondary dysmenorrhea depends on the underlying cause. Treatment for menorrhagia depends on the age of the woman, severity of the bleeding, whether or not she wants children in the future, and on any underlying medical condition. Hormone medication containing estrogen, progesterone, or both can be used to reduce the bleeding. If an IUD is the cause, it can be removed. A D&C, in which the endometrium lining is scraped away, may be beneficial if the lining has thickened and causes the excessive bleeding. The endometrial lining can also be thinned (endometrial ablation) using laser or electrocautery. If the condition is severe, or does not respond to treatment, the uterus may have to be surgically removed (hysterectomy). Metrorrhagia may be controlled by hormones, such as those in birth control pills (oral contraceptives). If bleeding becomes profuse (hemorrhage), bedrest and/or hospitalization may be required.

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

Menorrhagia

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.

Menorrhagia

Background
Menorrhagia is defined as menstruation at regular cycle intervals but with excessive flow and duration and is one of the most common gynecologic complaints in contemporary gynecology. Clinically, menorrhagia is defined as total blood loss exceeding 80 mL per cycle or menses lasting longer than 7 days.[1] The World Health Organization reports that 18 million women aged 30-55 years perceive their menstrual bleeding to be exorbitant.[2] Reports show that only 10% of these women experience blood loss severe enough to cause anemia or be clinically defined as menorrhagia.[1, 3, 4] In practice, measuring menstrual blood loss is difficult. Thus, the diagnosis is usually based upon the patient's history. A normal menstrual cycle is 21-35 days in duration, with bleeding lasting an average of 7 days and flow measuring 25-80 mL.[5] Menorrhagia must be distinguished clinically from other common gynecologic diagnoses. These include metrorrhagia (flow at irregular intervals), menometrorrhagia (frequent, excessive flow), polymenorrhea (bleeding at intervals < 21 d), and dysfunctional uterine bleeding (abnormal uterine bleeding without any obvious structural or systemic abnormality).[5] Nearly 30% of all hysterectomies performed in the United States are performed to alleviate heavy menstrual bleeding.[6] Historically, definitive surgical correction has been the mainstay of treatment for menorrhagia. Modern gynecology has trended toward conservative therapy both for controlling costs and the desire of many women to preserve their uterus. Heavy menstrual bleeding is a subjective finding, making the exact problem definition difficult. Treatment regimens must address the specific facet of the menstrual cycle the patient perceives to be abnormal, (ie, cycle length, quantity of bleeding). Finally, treatment success is usually evaluated subjectively by each patient, making positive outcome measurement difficult. Next Section: Pathophysiology

Amenorrhea Overview
Amenorrhea is the absence of menstrual bleeding and may be primary or secondary. Primary amenorrhea is the absence of menstrual bleeding and secondary sexual characteristics (for example, breast development and pubic hair) in a girl by age 14 years or the absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 years. Secondary amenorrhea is the absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for three or more months in the absence of pregnancy, lactation (the ability to breastfeed), cycle suppression with systemic hormonal contraceptive (birth control) pills, ormenopause. For a woman to have regular menstrual cycles, her hypothalamus, pituitary gland, ovaries, and uterus should all be functioning normally. The hypothalamus stimulates the pituitary gland to release folliclestimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH cause the ovaries to produce the hormones estrogen and progesterone. Estrogen and progesterone are responsible for the cyclical changes in the endometrium (uterine lining), including menstruation. In addition, a womans genital tract should be free of any abnormalities to allow the passage of menstrual blood.