Introduction
Background
Menstruation disorders are a common problem during adolescence. These disorders may cause significant anxiety for patients and their families.1 Physical and psychological factors contribute to the problem. In order to treat menstruation disorders, becoming familiar with the normal menstrual cycle is important.
For a regular menstrual cycle, the median age of menarche is 12.77 years. The average interval between thelarche and menarche is about 2 years, and 90% of females menstruate by the time they have Tanner IV breast and pubic hair development. Most cycles occur between 21-35 days with 3-10 days of bleeding and 30-40 mL of blood loss. Anovulatory cycles and irregular menstrual patterns are common within 24 months of menarche.
Classification of menstrual disorders
Attempts are currently underway to establish a standardized international nomenclature for menstrual disorders. The existing broad classification is as follows:
- Amenorrhea and oligomenorrhea (lack of bleeding or too little bleeding)
- Dysmenorrhea (painful menstruation)
- Menorrhagia (excessive bleeding)
Amenorrhea
Amenorrhea may be primary (ie, never menstruated) or secondary (ie, menarche, but no periods for 3 consecutive months). Primary amenorrhea is the absence of menstruation by age 16 years in the presence of normal pubertal development or by age 14 years in the absence of normal pubertal development. Evaluating for breast and uterine development in patients with a menstruation disorder is important. Secondary amenorrhea is more common than primary amenorrhea. The most common etiology is dysfunction of the hypothalamic-pituitary-ovarian (HPO) axis.
Dysmenorrhea
Dysmenorrhea is a very common complaint and may be primary or secondary, although primary dysmenorrhea is more prevalent. Symptoms include crampy lower abdominal and pelvic pain that radiates to the thighs and back without associated pelvic pathology. Dysmenorrhea is caused by prostaglandins and leukotrienes during ovulatory cycles. Endometrial prostaglandin levels increase during the luteal and menstrual phases of the cycle, causing uterine contractions. Secondary dysmenorrhea is rare, and pain is associated with pelvic pathology (eg, bicornuate uterus, endometriosis, pelvic inflammatory disease, uterine fibroids). An underlying pelvic pathology (eg, endometriosis) or an uterine anomaly (eg, fibroids) may be present in about 10% of severe dysmenorrhea cases.2
Menorrhagia
Menstrual bleeding that lasts more than 8-10 days with blood loss of over 80 mL is considered excessive.
Pathophysiology
Hormonal changes in the normal menstrual cycle
In the ovulatory cycle, the hypothalamus secretes gonadotropin-releasing hormone (GnRH), which stimulates the pituitary to release follicle-stimulating hormone (FSH). This, in turn, causes an ovarian follicle to grow and mature. In mid cycle, a surge of luteinizing hormone (LH) occurs with an FSH surge, resulting in ovulation. The developing follicle produces estrogen, which stimulates the endometrium to proliferate. After the ovum is released, FSH and LH levels fall, corpus luteum develops at the site of the ruptured follicle, and progesterone is secreted from the ovary. Progesterone causes the proliferating endometrium to differentiate and stabilize. Fourteen days after ovulation, menstruation results from endometrial shedding secondary to the rapid decline in the levels of estrogen and progesterone from the involuting corpus luteum.
Hormonal changes during anovulatory cycles
Anovulatory cycles are common in the first 2 years after menarche because of the immaturity of the HPO axis. They can also occur in various pathological conditions.
In anovulatory cycles, the follicular growth occurs with the stimulation from FSH; however, due to lack of LH surge, ovulation fails to occur. Consequently, no corpus luteum is formed and no progesterone is secreted. The endometrium continues its proliferative phase excessively. When the follicle involutes, estrogen levels drop and estrogen withdrawal bleeding occurs. Most anovulatory cycles are regular with normal bleeding; however, the unstable proliferative endometrium can shed irregularly, resulting in prolonged heavy bleeding.
Frequency
International
Twelve percent of all gynecology referrals in the United Kingdom are for heavy menstrual bleeding.
Clinical
History
- Amenorrhea
- Detailed history of pubertal development
- Family history of menarche, pubertal development
- History of weight loss, stress, exercise (athletic activity)
- Detailed dietary history
- History of contraception, medications
- History suggestive of CNS disease (eg, headaches, visual changes)
- History of chronic illnesses (eg, Crohn disease)
- Dysmenorrhea
- Evaluation should include a detailed menstrual history and the relationship of the pain to the menstrual cycle.
- Ask about a family history of endometriosis.
- Ascertain the degree of incapacitation. If pain is mild and physical examination is normal, a pelvic examination is not indicated. If pain is severe and interferes with daily living, a pelvic examination is warranted. If a patient is sexually active, a pelvic examination is mandatory. Be suspicious of secondary dysmenorrhea if onset of dysmenorrhea occurs at menarche.
- Menorrhagia
- Date of menarche
- Menstrual calendar (invaluable)
- Sexual activity
- Use of hormones, such as oral contraceptive pills or depo-medroxyprogesterone acetate, and use of other medications such as warfarin, aspirin
- Chronic illnesses
- Bleeding disorders, including family and personal history
- CNS symptoms
- Acne, hirsutism
Physical
- Amenorrhea
- Height, weight, and growth charts
- Breast development, pubic hair
- Syndromic appearance (eg, short stature, webbed neck)
- Visual fields, thorough neurologic examination, optic fundi
- Evidence of hyperandrogenism (eg, acne, hirsutism, clitoromegaly)
- Evidence of thyroid disease
- Evidence of chronic illnesses
- Evidence of pregnancy
- Menorrhagia
- Growth percentiles
- Palpation of thyroid
- Breast examination for galactorrhea
- Evidence of bleeding elsewhere
- Pelvic examination, if sexually active
Causes
- Primary amenorrhea with absent breast development and present uterus
- Constitutional delay of puberty
- Hypothalamic dysfunction (eg, stress, anorexia, chronic illness, exercise)
- Pituitary failure
- Gonadal failure
- Gonadal dysgenesis (eg, Turner syndrome, Swyer syndrome)
- Gonadotrophin deficiency (eg, Kallmann syndrome)
- Primary amenorrhea with breast development and present uterus
- Hyperandrogenic amenorrhea
- Hypothalamic amenorrhea
- Hypothyroidism
- Hyperprolactinemia
- Outflow tract obstructions (eg, imperforate hymen, vaginal atresia)
- Primary amenorrhea with breast development and absent uterus
- Müllerian agenesis
- Androgen insensitivity
- Menorrhagia
- Anovulatory dysfunctional uterine bleeding (DUB)
- Immature HPO axis, adolescent DUB
- Hyperandrogenic chronic anovulation (eg, polycystic ovarian syndrome, adrenal hyperplasia)
- Pregnancy-related complications
- Sexually transmitted diseases
- Chronic illnesses
- Blood dyscrasia
- Trauma
- Drugs
- Endocrine disorders
- Neoplasms
More on Menstruation Disorders |
 Overview: Menstruation Disorders |
| Differential Diagnoses & Workup: Menstruation Disorders |
| Treatment & Medication: Menstruation Disorders |
| Follow-up: Menstruation Disorders |
| References |
| Next Page » |
References
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James AH, Kouides PA, Abdul-Kadir R, Edlund M, Federici AB, Halimeh S, et al. Von Willebrand disease and other bleeding disorders in women: Consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. May 28 2009;[Medline].
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG committee opinion. No. 337: Noncontraceptive uses of the levonorgestrel intrauterine system. Obstet Gynecol. Jun 2006;107(6):1479-82. [Medline].
[Best Evidence] Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006;(2):CD003855. [Medline].
Braverman PK, Sondheimer SJ. Menstrual disorders. Pediatr Rev. Jan 1997;18(1):17-25; quiz 26. [Medline].
Emans JS, Laufer M, Goldstein DP. Delayed puberty and menstrual irregularities. In: Pediatric and Adolescent Gynecology. 4th ed. 1998:163-261.
Gordon CM. Menstrual disorders in adolescents. Excess androgens and the polycystic ovary syndrome. Pediatr Clin North Am. Jun 1999;46(3):519-43. [Medline].
Harlow SD, Campbell OM. Epidemiology of menstrual disorders in developing countries: a systematic review. BJOG. Jan 2004;111(1):6-16. [Medline].
Iglesias EA, Coupey SM. Menstrual cycle abnormalities: diagnosis and management. Adolesc Med. Jun 1999;10(2):255-73. [Medline].
Mitan LA, Slap GB. Adolescent menstrual disorders. Update. Med Clin North Am. Jul 2000;84(4):851-68. [Medline].
Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol. Feb 2003;17(1):75-92. [Medline].
Further Reading
Keywords
menstruation disorders, irregularities of menstruation, menstrual disorders, amenorrhea, oligomenorrhea, dysmenorrhea, secondary dysmenorrhea, painful menstruation, menorrhagia, anovulatory cycles, irregular menstrual patterns, thelarche, menarche, dysfunctional uterine bleeding, DUB, menstruation disorders, hypothalamic-pituitary-ovarian axis, HPO axis, endometriosis, pelvic inflammatory disease, uterine fibroids, Crohn disease, constitutional delay of puberty, hypothalamic dysfunction, pituitary failure, gonadal failure, Turner Syndrome, Swyer syndrome, gonadotrophin deficiency, Kallmann syndrome, hyperandrogenic amenorrhea, hypothalamic amenorrhea, hypothyroidism, hyperprolactinemia, outflow tract obstructions, imperforate hymen, vaginal atresia, Müllerian agenesis, androgen insensitivity
