Normal menstrual function is the result of a complex interaction between the hypothalamus, pituitary gland, ovaries and endometrium. Any interruption of this axis at any point may lead to disordered menstruation. Many types of menstrual disorders occur in adult women who have normal sexual maturation. These disorders include absence of menstruation (amenorrhea); painful menstruation (dysmenorrhea); dysfunctional uterine bleeding (anovulatory bleeding); excessive blood loss during each menstrual cycle (menorrhagia); and irregular bleeding (metrorrhagia).
In addition, many women experience premenstrual syndrome, a group of physical and emotional symptoms that occur before the onset of each cycle. Also, a few women have transient abdominal discomfort at the time of ovulation because of slight bleeding from the follicle into the peritoneal cavity; oral contraceptives will remedy the condition by suppression of ovulation, or the discomfort can be treated with pain medications such as ibuprofen or naproxen.
Amenorrhea (absence of menstrual periods)
Amenorrhea is a reflection of some failure in the integrally interconnected neuroendocrine feedback loop between the hypothalamus, the pituitary gland, the ovaries, and the uterus which control the menstrual cycle. However, amenorrhea is not itself a disease.
There are two categories of amenorrhea, primary and secondary amenorrhea. Primary amenorrhea is the delay or failure of a young woman to start menstruating upon reaching the age of 16. The course of puberty and the age of menarche vary so widely that there should be no worry until the girl reaches the age of 16, provided that there are other signs of early pubertal changes (growth spurt, underarm or pubic hair, breast development). Treatment for primary amenorrhea usually is not undertaken until the age of 18.
Secondary amenorrhea refers to the lack of menstruation that occurs in women who had previously been menstruating but then ceases menstruation for at least three cycles. It is much more common than primary amenorrhea. However, unless symptoms are extreme or there is another underlying problem, such as inability to conceive, there is no pressing need for treatment.
Causes of primary amenorrhea may include chromosomal disorders such as Turner’s syndrome (a genetic disorder that prevents sexual maturing in girls); hypothalamic or pituitary diseases; moderate or excessive exercise; dietary deficiencies resulting from disorders such as anorexia nervosa and obesity; extreme physical or psychological stress or a combination of both; and adverse effect of a variety of medication including some tranquilisers and progesterone. The common causes of secondary amenorrhea include many of those listed for primary amenorrhea as well as pregnancy; ovarian cysts and/or tumors; extreme weight loss and/or vigorous physical activity; radiation therapy or an abnormally adherent placenta in a prior pregnancy; and damage to the pituitary.
Diagnosis of both types of amenorrhea is usually directed at finding an organic cause, usually by process of elimination. This involves taking a very detailed medical history, followed by a careful physical examination, preferably including a pelvic examination and a skull X-ray to rule out pituitary tumors. Additionally, laboratory tests of urine and vaginal smears may be necessary for secondary amenorrhea.
Treatment of amenorrhea is determined by its cause. Hormone therapy can be effective for primary amenorrhea caused by hormonal changes. Surgery can sometimes alleviate cases related to hereditary problems. For secondary amenorrhea, sometimes lifestyle changes can help if weight, stress, or physical activity is causing the amenorrhea. Other times medications and oral contraceptives can help the problem.
Dysmenorrhea (painful menstruation)
It is also referred to as menstrual cramps. Painful cramps or spasms of dull and/or acute lower abdominal discomfort, felt before or during menstruation. The pain normally involves only the lower abdominal and genital area, but sometimes it is felt in the lower back, on the inner thighs and throughout the pelvis. Along with pain, some women experience nausea, vomiting, dizziness and fainting. In most women, cramps tend to lessen in severity after the age of 30. In 5% or so of women the condition is severe enough to interfere significantly with their lives.
Dysmenorrhea may be primary or secondary. Primary dysmenorrhea may occur a few days before the period, at the onset of bleeding, or during the total episode. The pain varies from a severe incapacitating distress to relatively minor and brief intense cramps. Other symptoms may include irritability, fatigue, backache, headache, leg pains, nausea, vomiting, and cramping.
Primary dysmenorrhea is caused by the endocrine system’s release of excessive amounts of prostaglandins that stimulate the uterus to contract, thus causing the familiar cramps of the disorder. Drugs that block prostaglandin formation can decrease the severity of uterine contractions and can eliminate pain for many women with dysmenorrhea.
Secondary dysmenorrhea is much less common. It most often results from genital obstructions, pelvic inflammation or degeneration, abnormal uterine wall separation or development (i.e., endometriosis), chronic infection of the uterus, polyps or tumors, or weakness of the muscles that support the uterus. Tumors produce sharper pains.
Women have long used a variety of home remedies for cramps. Antiprostaglandin medications include aspirin, ibuprofen, fenoprofen calcium, mefenamic acid, naproxen sodium, and naproxen. Heat tends to relax the spasms, and relief often is afforded by use of a heating pad or a hotwater bottle or deep-heating oil (such as tiger balm).
Anovulatory bleeding (dysfunctional uterine bleeding)
Anovulatory bleeding refers to any abnormal bleeding from the vagina that cannot be considered as part of the normal menstruation cycle. This occurs most often in the first two or three years following menarche and again in the five or so years preceding menopause.
Without ovulation in the normal course of the menstrual cycle, no progesterone is produced. The extra endometrial tissue built up during the follicular phase is eventually shed, but not at the regular rate and time that it would have occurred in the instance of ovulation. Progesterone regulates the timing of the menstrual cycle, and without it menstruation becomes irregular or may cease altogether, or it may involve heavy, long-lasting menstrual periods.
Experts believe that 20% of ovulation failures are the result of excessive heavy physical exercises, obesity, chronic illness, excess androgen production, thyroid gland dysfunction, excess prolactin production or psychologically seated sexual problems and anxieties. The administration of oral progesterone often will stop heavy bleeding but cannot reinstate ovulation.
Menorrhagia (Heavy Periods)
It is a fairly common disorder that is characterized by an unusually heavy cyclical menstrual blood loss over several consecutive cycles without any intermenstrual or post-coital bleeding. Menorrhagia may be due to an imbalance of the thyroid or adrenal hormones but may also be the result of local disease of the pelvic organs. The average amount of blood loss during a normal menstrual period is about 2 ounces while with menorrhagia a woman may lose about 3 ounces or more.
Causes of menorrhagia include anovulation; imbalance of female hormones (estrogen and progesterone); fibroids; pelvic infection; endometrial disorder; intrauterine device (IUD); and hypothyroidism. For treatment, some types of local pelvic disease may require removal of the uterus (hysterectomy) or treatment by chemotherapy or radiation, but polyps and some fibroids can be removed without loss of the uterus.
Metrorrhagia (Irregular/Spotty Bleeding)
This refers to bleeding from the vagina between regular menstrual cycles. Some women also have spotting following sexual intercourse. Such bleeding may come from some abnormality of the cervix (possibly a cancer); a polyp on the cervix; or a cervical erosion. Treatment is often unnecessary, but erosions are easily treated by cauterization. Polyps require removal.
Other disorders associated with the menstrual cycle include the following:
Oligomenorrhea (prolonged intervals between menses)
Most women of reproductive age menstruate every 25 to 30 days if they are not pregnant, nursing a child, or experiencing other disorders such as tumours, or anorexia nervosa. In oligomenorrhea, menstruation occurs with intervals of 35 or more days between menstrual periods. It is particularly common at menarche during the first few years of menstruation and during perimenopause. The cause of the disorder may be occasional emotional problems, crash diets and obesity, hormonal, or structural in nature.
Polymenorrhea (frequent interval between menses)
This is characterized with frequent menstrual periods, with intervals of fewer than 20 days between menstrual flows. It may also be caused by a uterine fibroid. It usually signifies a hormone imbalance, that is, too much estrogen in the absence of progesterone (or relative to progesterone), a condition found mostly in young girls who are not yet ovulating and in women approaching menopause. Some women routinely menstruate every 19 or 20 days and, in the absence of anaemia or other problems, such a short menstrual cycle is no cause for alarm or for treatment.