Menstruation Disorders 

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.^[5] 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.^[7]

Menorrhagia

Menstrual bleeding that lasts more than 8-10 days with blood loss of over 80 mL is considered excessive.

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.