Menstrual Disorders

Definition

A menstrual disorder is a physical or emotional problem that interferes with the normal menstrual cycle, causing pain, unusually heavy or light bleeding, delayed menarche, or missed periods.

Description

Typically, a woman of childbearing age should menstruate every 28 days or so unless she is pregnant or moving into menopause. But numerous things can go wrong with the normal menstrual cycle, some the result of physical causes, others emotional. These include amenorrhea, or the cessation of menstruation, menorrhagia, or heavy bleeding, and dysmenorrhea, or severe menstrual cramps. Nearly every woman will experience one or more of these menstrual irregularities at some time in her life.

Amenorrhea

There are two types of amenorrhea: primary and secondary. Overall, they affect 2-5% of childbearing women, a number that is considerably higher among female athletes (possibly as high as 66%).

Primary amenorrhea occurs when a girl at least 16 years old is not menstruating. Young girls may not have regular periods for their first year or two, or their periods may be very light, a condition known as oligomenorrhea. A light flow is nothing to worry about. But if the period has not begun at all by age 16, there may be something wrong. Amenorrhea is most common in girls who are severely underweight and/or exercise intensely, both of which affect the amount of body fat necessary to trigger the release of hormones that, in turn, begins puberty.

Secondary amenorrhea occurs in women of childbearing age after a period of normal menstruation and is diagnosed when menstruation has stopped for three months. It can occur in women of any age.

Dysmenorrhea

Characterized by menstrual cramps or painful periods, dysmenorrhea, which comes from the Greek words for "painful flow," affects nearly every woman at some point in her life. It is the most common reproductive problem in women, resulting in numerous days absent from school, work, and other activities. There are two types: primary and secondary.

Primary, or normal cramps, affects up to 90% of all women, usually occurring in women about three years after they start menstruating and continuing through their mid-twenties or until they have a child. About 10% of women who have this type of dysmenorrhea cannot work, attend school, or participate in their normal activities. It may be accompanied by backache, dizziness, headache, nausea, vomiting, diarrhea and tenseness. The symptoms typically start a day or two before menstruation, usually ending when menstruation actually begins.

Secondary dysmenorrhea has an underlying physical cause and primarily affects older women, although it may also occur immediately after a woman begins menstruation.

Menorrhagia

Menorrhagia, or heavy bleeding, most commonly occurs in the years just before menopause or just after women start menstruating. It occurs in 15-20% of American women.

Premenstrual dysphoric disorder (PMDD)

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, lists premenstrual dysphoric disorder (PMDD) in an appendix of criteria sets for further study. To meet full criteria for PMDD, a patient must have at least five out of 11 emotional or physical symptoms during the week preceding the menses for most menstrual cycles over the previous 12 months. Although the DSM-IV definition of PMDD as a mental disorder is controversial because of fear that it could be used to justify prejudice or job discrimination against women, there is evidence that a significant proportion of premenopausal women suffer emotional distress or impairment in job functioning in the week before their menstrual period. One group of researchers estimates that 3-8% of women of childbearing age meet the strict DSM-IV criteria for PMDD, with another 13-18% having symptoms severe enough to interfere with their normal activities.

Causes and symptoms

Amenorrhea

The only symptom of primary amenorrhea is delayed menstruation. In addition to low body weight or excessive exercise, other causes of primary amenorrhea include Turner's syndrome, a birth defect related to the reproductive system, or ovarian problems. In 2003, a group of researchers reported on a new genetic mutation associated with primary amenorrhea. In secondary amenorrhea, the primary symptom is the ceasing of menstruation for at least three months. Causes include pregnancy or breastfeeding, sudden weight loss or gain, intense exercise, stress, endocrine disorders affecting the thyroid, pituitary or adrenal glands, including Cushing's Syndrome and hyperthyroidism, problems with or surgery on the ovaries, including removal of the ovaries, cysts or ovarian tumors.

Amenorrhea in athletes or dancers is frequently associated with two other disorders—osteopenia, or reduced bone mass, and eating disorders. This combination is sometimes called the female athlete triad. Osteopenia is of concern because it can lead to premature osteoporosis.

Dysmenorrhea

Primary dysmenorrhea is related to the production of prostaglandins, natural chemicals the body makes that cause an inflammatory reaction. They also cause the muscles of the uterus to contract, thus helping the uterus shed the lining built up during the first part of a woman's cycle. Women with severe menstrual pain have higher levels of prostaglandin in their menstrual blood than women who do not have such pain. In some women, prostaglandins can cause some of the smooth muscles in the gastrointestinal tract to contract, resulting in the nausea, vomiting and diarrhea some women experience. Prostaglandins also cause the arteries and veins to expand, so that blood collects in them rather than flowing freely through them, causing pain and heaviness. Yet another reason for severe cramps, particularly in women who have not yet had a baby, is that the flow of the blood and clots through the tiny cervical opening is painful. After a woman has a baby, however, the cervix opening is larger.

Secondary dysmenorrhea is more serious and is related to some underlying cause. The pain may feel like regular menstrual cramps, but may last longer than normal and occur throughout the month. It may be stronger on one side of the body than the other. Possible causes include:

• A tipped uterus
• Endometriosis, a condition in which the same type of tissue found in the lining of the uterus occurs outside the uterus, usually elsewhere in the pelvic cavity
• Adenomyosis, a condition in which the endometrial lining grows into the muscle of the uterus
• Fibroids
• Pelvic inflammatory disease (PID)
• An IUD
• A uterine, ovarian, bowel or bladder tumor
• Uterine polyps
• Inflammatory bowel disease
• Scarring or adhesions from earlier surgery

Menorrhagia

Heavy bleeding during menstruation is usually related to a hormonal imbalance, although other causes include fibroids, cervical or endometrial polyps, the autoimmune disease lupus, pelvic inflammatory disease (PID), blood platelet disorder, a hereditary blood factor deficiency, or, possibly, some reproductive cancers. Thus, menorrhagia is actually a symptom of an underlying condition rather than a disease itself. It may also be related to the use of an IUD.

Women with menorrhagia experience not only significant inconvenience, but may feel very tired due to the loss of iron-rich blood. It is usually diagnosed when a woman soaks through a tampon or pad every hour for several hours or has a period lasting more than 7 days. Clots are not related to menorrhagia, although women with heavy cycles may pass clots. They are typically a normal part of menstruation, more common when a woman has been sitting or in a stationary position for a while

Diagnosis

Women should seek care from a gynecologist, family practitioner or internist for menstrual irregularities. Depending on the problem, various tests and procedures will be performed, but the one common to any menstrual problem is a pelvic exam. This should be scheduled when women are not menstruating, simply for conveniencee.

Male doctors typically have a female nurse or assistant in the room. The examination begins by checking the external genitalia for any sores or irregularities. Then the doctor inserts a speculum (a metal duckbill-shaped device that holds open the vagina) into the vagina and peers throughout the opening to evaluate the health of the cervix (opening of the uterus), and inside the vagina, looking for growths or any other abnormalities.

The doctor will also manually examine the woman, inserting two fingers into the vagina while pressing on the abdomen, again feeling for any lumps or other abnormalities, checking the size and shape of the reproductive organs, and watching for any signs of infection, such as tenderness or pain. The exam is typically covered by insurance and takes about 10 minutes.

Other tests that will be done for menstrual irregularities include:

• A pregnancy test. The nurse takes some blood from a woman's arm and it is tested for the presence of certain hormones that indicate a pregnancy has occurred.
• Ultrasound. Typically performed by a trained ultrasound technologist, it involves using sound waves to get an image of the reproductive system. It is used to look for fibroids and other ovarian abnormalities that may cause heavy bleeding or cramps. Typically, the technologist will smear a jelly over the woman's stomach, then place a probe on her stomach and watch the images appear on a computer screen. It is painless. Women may be asked not to urinate for several hours prior to the test, as a full bladder makes it easier to see the other internal organs. The test takes about 20 minutes.
• Endometrial biopsy. Used to check the health of uterine tissue in women who have unusually heavy bleeding, this test should be performed by the physician. Women should take a pain reliever such as ibuprofen or naproxen prior to the procedure, as there may be some cramping. The woman lies back on the table with her feet in stirrups and the doctor inserts a speculum, then opens the cervix slightly with an instrument called a tenaculum. Then the doctor slides a small, hollow catheter into the uterus and sucks out a small piece of tissue from the uterine lining. The tissue is then examined for any abnormalities in a laboratory. The test takes about 30 minutes and is typically covered by insurance. Some bleeding may result afterwards.
• Blood, stool and urine tests may also be conducted to check for levels of various hormones, blood cells, and other chemicals.
• Dilation and curettage (D&C): During this minor surgical procedure, the cervix is opened and the lining of the uterus scraped for a tissue sample.
• Laparascopy and hysteroscopy: in some instances, these surgical procedures, in which a small camera is inserted into the woman to view the inside of the pelvis, abdomen or uterus.

Treatment

Amenorrhea

For primary amenorrhea with no underlying problem, no treatment is necessary, and a wait-and-see approach is often adopted. If women have genetic or hormonal abnormalities, amenorrhea is often treated with oral contraceptives that contain combinations of estrogen and progestin. Side effects include bloating, weight gain and acne, although some birth control pills actually improve acne. Progestins, or synthetic progesterone, are also used alone to "jump start" a woman's period. They include medroxyprogesterone (Provera, Amen, Depo-Provera ), norethindrone acetate (Aygestin, Norlutate), and norgestrel (Ovrel). If the amenorrhia is due to a physical problem, such as a closed vagina, surgery may be required.

With secondary amenorrhia, treatment depends on the cause. Hormonal imbalances are treated with supplemental hormones. Tumors or cysts may require surgery. Obesity may require a diet and exercise regimen, while amenorrhia resulting from too much dieting or exercise necessitates lifestyle changes.

Dysmenorrhea

Primary dysmenorrhea is typically treated with nonsteroidal anti-inflammatory medications like ibuprofen and naproxen, which studies show help 64 to 100% of women. Birth control pills relieve pain and symptoms in about 90% of women by suppressing ovulation and reducing the amount of menstrual blood. It may take up to three cycles before a woman feels relief. Heat from a heating pad or hot bath, can also help relieve pain.

Treatment for secondary dysmenorrhea depends on the underlying cause of the condition.

Menorrhagia

If there are no other problems, and the bleeding is due to hormonal imbalances, birth control pills are often prescribed to bring the bleeding under control and regulate menstruation. Such medications as ibuprofen and naproxen can also help reduce the bleeding and any cramping associated with it. In severe cases, doctors may recommend removing the uterus during a hysterectomy, or performing some form of endometrial ablation, which removes the lining of the uterus. These procedures are typically only offered to women who have completed their families. A recent British study reported, however, that many women prefer endometrial ablation to hysterectomy because it is less invasive and safer. A new treatment that involves intrauterine hormonal therapy is gaining acceptance, but had not been approved by the FDA as of spring 2004.

Premenstrual dysphoric disorder (PMDD)

Medications that have been reported to be effective in treating PMDD include the tricyclic antidepressants and the selective serotonin reuptake inhibitors (SSRIs). Effective treatments other than medications include cognitive behavioral therapy (CBT), aerobic exercise, and dietary supplements containing calcium, magnesium, and vitamin B₆.

Alternative treatment

Amenorrhea

There are several herbal remedies that can bring on menstruation, including: black cohosh, cramp bark, chasteberry, celery, turmeric, and marsh mallow. Numerous relaxation techniques, such as meditation, deep breathing, and yoga can help reduce stress and its affects on menstruation.

Dysmenorrhea

Numerous alternative treatments may help relieve the menstrual pain. These include:

• Transcutaneous electrical nerve stimulation (TENS), which several studies found, relieved pain in 42-60% of participants, working faster than naproxen in one study.
• Acupuncture: One study of 43 patients followed for a year found that 90% of those who had acupuncture once a week for three menstrual cycles had less pain, and 43% used less pain medication.
• Omega-3 fatty acids: Often sold as fish oil supplements, they are a known anti-inflammatory, working against the effects of prostaglandins. Studies found that women with low amounts of omega-3 fatty acids in their diets were more likely to have menstrual cramps; those who took supplements had less pain.
• Vitamin B-1: One large study found that symptoms disappeared in 87% of women who took 100 mg a day for 90 days.
• Magnesium supplements: One study of 30 women who took 4.5 milligrams of oral magnesium three times daily for part of the month decreased their symptoms up to 84%.

Menorrhagia

Herbs used to treat menorrhagia include yarrow, nettles and shepherd's purse, as well as agrimony, particularly used in Chinese medicine, ladies mantle, vervain and red raspberry, which are thought to strengthen the uterus. Vitex is another herb recommended for a variety of menstrual disorders ranging from menorrhagia to PMS. Women may want to make sure they are taking an iron supplement to replace the iron lost during the heavy bleeding, although they should check with their doctor to make sure they do not suffer from a condition of having too much iron. Helpful vitamins include vitamin A, because women with heavy bleeding typically have lower levels of Vitamin A, K, which aids in clotting, and C and bioflavinoids which help strengthen veins and capillaries. Zinc may also help.

Prognosis

The prognosis for all menstrual irregularities is good once treatment is initiated.

Prevention

Amenorrhea

Simply following a healthy exercise and nutritional program can help prevent amenorrhea, as can reducing stress and learning relaxation techniques. Also, avoiding excessive alcohol intake and quitting smoking may prevent missed periods.

Dysmenorrhea

Prevention includes certain dietary supplements and vitamins described above. Exercise may also help.

Menorrhagia

There is little women can do to prevent this menstrual irregularity other than discovering the root cause. One thing they can do, however, is stop using an IUD, which can often cause heavier bleeding.

KEY TERMS

Adenomyosis— Uterine thickening caused when endometrial tissue, which normally lines the uterus, extends outward into the fibrous and muscular tissue of the uterus.

Cervical polyps— Growths originating from the surface of the cervix or endocervical canal. These small, fragile growths hang from a stalk and protrude through the cervical opening (the os).

Cushing's syndrome— A group of conditions caused by increased production of cortisol hormones or by the administration of glucocorticoid hormones (cortisone-like hormones).

Endometriosis— A condition in which the tissue that normally lines the uterus (endometrium) grows in other areas of the body, causing pain, irregular bleeding, and frequently, infertility.

Fibroids— Benign tumors of muscle and connective tissue that develop within or are attached to the uterine wall.

Hyperthyroidism— An imbalance in metabolism that occurs from overproduction of thyroid hormone.

Inflammatory bowel disease— A chronic inflammatory disease that can affect any part of the gastrointestinal tract but most commonly affects the ileum.

Lupus (systemic lupus erythematosus or SLE)— A chronic inflammatory autoimmune disorder that may affect many organ systems including the skin, joints, and internal organs.

Menarche— The first menstrual period or the establishment of the menstrual function.

Osteopenia— Reduction in bone mass, usually caused by a lowered rate of formation of new bone that is insufficient to keep up with the rate of bone destruction. Osteopenia often occurs together with amenorrhea and eating disorders in female athletes. It can lead to premature osteoporosis if left untreated.

Pelvic inflammatory disease (PID)— A general term referring to infection involving the lining of the uterus, the Fallopian tubes, or the ovaries.

Turner's syndrome— A disorder in women caused by an inherited chromosomal defect. This disorder inhibits sexual development and causes infertility. A symptom is absence of menstruation.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Menstrual Abnormalities and Abnormal Uterine Bleeding." Section 18, Chapter 235. In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II. "CAM Therapies for Specific Conditions: Menstrual Symptoms, Menopause, and PMS." New York: Simon & Schuster, 2002.

PERIODICALS

Aegerter, Ch., D. Friess, and L. Alberio. "Menorrhagia Caused by Severe Hereditary Factor VII Deficiency. Case 1." Hämostaseologie 23 (August 2003): 99-102.

Donaldson, M. L. "The Female Athlete Triad. A Growing Health Concern." Orthopedic Nursing 22 (September-October 2003): 322-324.

Halbreich, U., J. Borenstein, T. Pearlstein, and L. S. Kahn. "The Prevalence, Impairment, Impact, and Burden of Premenstrual Dysphoric Disorder (PMS/PMDD)." Psychoneuroendocrinology 28, Supplement 3 (August 2003): 1-23.

Meduri, G., P. Touraine, I. Beau, et al. "Delayed Puberty and Primary Amenorrhea Associated with a Novel Mutation of the Human Follicle-Stimulating Hormone Receptor: Clinical, Histological, and Molecular Studies." Journal of Clinical Endocrinology and Metabolism 88 (August 2003): 3491-3498.

Paddison, K. "Menorrhagia: Endometrial Ablation or Hysterectomy?" Nursing Standard 18 (September 17-23): 33-37.

Rapkin, A. "A Review of Treatment of Premenstrual Syndrome and Premenstrual Dysphoric Disorder." Psychoneuroendocrinology 28, Supplement 3 (August 2003): 39-53.

"Research Eyes IUS Use for Menstrual Bleeding." Contraceptive Technology Update Supplement 3 (June 2004): 67-69.

ORGANIZATIONS

Advancement of Women's Health Research. 1828 L Street, N.W., Suite 625 Washington, DC 20036. 202-223-8224. 〈http://www.womens-health.org〉.

American College of Obstetricians and Gynecologists (ACOG). 409 12th Street, SW, P. O. Box 96920, Washington, DC 20090-6920. 〈http://www.acog.org〉.

American Psychiatric Association (APA). 1400 K Street, NW, Washington, DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

National Women's Health Resource Center. 120 Albany Street Suite 820, New Brunswick, NJ 08901. (877) 986-9472. 〈www.healthywomen.org〉.

Menstrual Disorders

Kim’s Story

What Is Menstruation?

What Is Normal?

What Are Menstrual Disorders?

Treatment for Menstrual Disorders

Resources

Menstrual (MEN-stroo-al) disorders result in abnormal menstrual periods. Usually, these disorders occur when the hormones* that control menstruation (men-stroo-AY-shun) are out of balance, but in some cases another medical problem is the cause. Menstrual disorders include pain during periods, changes in the length of the menstrual cycle, and heavy, prolonged, or too frequent periods.

KEYWORDS

for searching the Internet and other reference sources

Abnormal uterine bleeding

Amenorrhea

Gynecology

Ovulation

Reproductive medicine

Uterus

Kim’s Story

Kim plays soccer in the fall, plays basketball in the winter, and does gymnastics in the spring and summer. Her friends call her the “lean, mean, fighting machine,” because she is almost all muscle and no fat. Kim is proud of her athletic ability, but she wishes her body had a few more curves. She feels self-conscious because she just turned 16 and still has not gotten her period, whereas all of her friends got their first period years ago. Kim is embarrassed and a little bit scared, because her mother made Kim an appointment with a gynecologist* to find out why Kim has not had her period.

*hormones

are chemicals that are produced by different glands in the body. Hormones are like the body’s ambassadors: they are created in one place but are sent through the body to have specific regulatory effects in different places.

*gynecologist

(gy-ne-KOL-o-jist) is a doctor who specializes in the reproductive system of women.

The doctor examined Kim and asked her a number of family history and health questions, including questions about sports and how long she has been playing. She told Kim that there was probably nothing wrong with her; some girls just get their period later than others. To be sure, the doctor ordered some blood tests that would show if Kim had a medical condition affecting her menstrual cycle. The tests showed that there was nothing wrong, and three months later Kim got her first period.

What Is Menstruation?

Menstruation, also called menses (MEN-seez), is a normal part of being a healthy female of reproductive age. During menstruation, the lining of a woman’s uterus (YOO-ter-us) is shed, resulting in blood and tissue being expelled from the body.

Menstruation is just one part of a cycle that the female reproductive system undergoes each month when a woman is not pregnant. The female reproductive system, located in the abdomen*, consists of two ovaries (O-va-reez), two fallopian (fa-LO-pe-an) tubes, and the uterus, cervix (SER-viks), and vagina (va-JY-na). The almond-sized ovaries contain the female reproductive cells, or eggs. The ovaries also make chemicals called hormones that act as messengers throughout the body. Eggs are carried through the fallopian tubes to the uterus, which is a pear-shaped, muscular organ in which a fertilized egg can grow and develop into a baby. If the egg is not fertilized, the lining of the uterus, which had thickened in preparation for pregnancy, is shed. The blood and tissue fragments exit the uterus through its opening, the cervix, and travel through the vagina to the outside of the body.

*abdomen

(AB-do-men), commonly called the belly, is the portion of the body between the chest and the pelvis.

The menstrual cycle is controlled by hormones that are in a delicate balance. The hormones interact with each other and with the reproductive organs to either take care of a fertilized egg that will become a baby or cause menstruation to occur.

The hormonal balancing act: a typical menstrual cycle

The following are the major events in a typical menstrual cycle.

• Day 0 to 5: At the very beginning of the cycle, the levels of the hormones estrogen (ES-tro-jen) and progesterone (pro-JES-te-rone) in the body are low. Menstruation begins, and blood and tissue are expelled from the uterus. The ovaries begin making more estrogen, and the lining of uterus, called the endometrium (en-do-ME-tree-um), begins to thicken. Meanwhile, an egg in one of the ovaries begins to mature in a small sac of tissue.
• Day 14: The egg leaves the ovary (which is called ovulation [ov-yoo-LAY-shun]) and travels through the fallopian tube to the uterus. Ovulation is controlled by gonadotropin (gon-a-do-TRO-pin)-releasing hormone (GnRH), follicle (FOL-i-kul)-stimulating hormone (FSH), and luteinizing (LOO-tee-in-eye-zing) hormone (LH). The empty sac in the ovary that once held the egg is now called the corpus luteum (KOR-pus LOO-te-um), and it makes the hormone progesterone. The combination of estrogen and progesterone cause the endometrium to keep growing thicker. A woman can get pregnant just before, during, or right after ovulation. If the egg is fertilized, the thickened endometrium is ready to nourish the developing embryo*.

*embryo

(EM-bree-o) in humans, an embryo is the developing organism from the end of the second week after fertilization to the end of the eighth week.

• Day 17 to 27: If the egg is not fertilized, hormone levels decrease.
• Day 28: The endometrium begins to break down, and menstruation begins. The hormone prostaglandin (pros-ta-GLAN-din) is produced by cells in the uterine lining. Prostaglandin causes blood vessels to narrow, which slows the supply of oxygen to the uterus and causes the muscles of the uterus to contract. This process helps to expel the blood and tissue of the uterine lining.

What Is Normal?

In a woman who is not pregnant, the menstrual cycle occurs approximately every 28 days. However, the length of the cycle can vary from 21 to 35 days in normal healthy girls and women. Cycle length is calculated from the first day of one period to the first day of the next. Usually, bleeding lasts for a period of several days, hence the term menstrual “period.” A woman wears a pad in her panties or a tampon inserted into the vagina to absorb the blood.

The first time a young girl gets her period is called menarche (MEN-ar-kee) and can be a scary thing or a much anticipated event, depending on the girl. In the United States, the average age when menarche occurs is 12, but some girls start menstruating at 10, others at 16. After menarche, a woman usually will get her period for 30 to 40 more years, until she goes through menopause*.

*menopause

(MEN-o-pawz) is the time in a woman’s life when she stops having periods and can no longer become pregnant.

There is huge variation among women in the length and duration of their menstrual cycle and whether they bleed a lot or a little. Some women have a period every 23 days, others every 35. Some periods last 3 days, whereas others last 7. And some women use 3 tampons or pads a day, whereas others need 10. Because of this wide range of “normal,” determining if a woman has a menstrual disorder can be difficult. It requires that a woman knows her own body and what is normal for her.

What Are Menstrual Disorders?

Menstrual disorders occur when something goes wrong with the normal monthly menstrual cycle. There are many different types of disorders. Usually, they occur when the hormones controlling menstruation are out of balance for some reason. However, menstrual disorders can be caused by underlying medical conditions. A woman who experiences changes in her menstrual cycle, especially if these changes include heavy bleeding or cause problems with daily living, should see her doctor right away.

Disorders in menstrual cycle length

Amenorrhea (a-men-o-REE-a) means “no menstrual periods.” Primary amenorrhea means not ever having a first period. Secondary amenorrhea is when a women or girl stops getting her monthly period.

A related problem is oligomenorrhea (OL-i-go-men-o-REE-a), which means having menstrual periods that are more than 35 days apart. Once doctors diagnose problems with menstrual cycle length, they then try to find out what is causing it.

Shelly, a 25-year-old woman who usually gets her periods like clockwork, stopped having her period for 3 months. The first thing her doctor ordered was a pregnancy test; it was a surprise to Shelly and her husband, but she was pregnant. Pregnancy is the most common cause of amenorrhea in women in their reproductive years.

When Anne turned 48, the amount of time between her periods started getting longer and longer. When she did not get her period for 4 months, she went to see her doctor. The doctor examined Anne and did some tests; Anne’s amenorrhea was caused by approaching menopause. Menopause is another perfectly natural cause of amenorrhea.

Kim provides a good example of primary amenorrhea, which refers to a girl not getting her first period by the time she is 16. This condition may be caused by a hormonal imbalance or a developmental problem. Young female athletes often experience primary or secondary amenorrhea or both; strenuous exercise seems to lower estrogen levels, thus causing periods to stop. Altered hormone levels can cause anovulation (an-ov-yoo-LAY-shun), when ovulation does not occur, which in turn often causes amenorrhea. Hormones are affected when a woman exercises too much, loses or gains a lot of weight, is stressed, is breast-feeding a baby, or has an eating disorder; all these things can lead to amenorrhea.

Medical problems, such as cysts (fluid-filled sacs) in the ovaries, abnormal growths or tumors* in the reproductive organs, anorexia nervosa*, and diabetes*, can also cause amenorrhea or oligomenorrhea.

*tumors

(TOO-morz) usually refer to abnormal growths of body tissue that have no known cause. Tumors may or may not be cancerous.

*anorexia nervosa

(an-o-REK-se-a ner-VO-sa) is an emotional disorder characterized by dread of gaining weight leading to self-starvation and dangerous loss of weight and malnutrition.

*diabetes

(dy-a-BEE-teez) is an impaired ability to break down carbohydrates, proteins, and fats because the body does not produce enough insulin or cannot use the insulin it makes.

Bleeding disorders Sometimes women have menstrual disorders in which they bleed too much, too often, or for too long. For example, Sally has menorrhagia (men-o-RA-jah), which means very heavy periods, and the bleeding goes on for almost 12 days. Sally will not even go to work on the first day of her period; she goes through a tampon and a pad every hour for the first five hours, and every month she ends up with bloodstains on her pants. Barb, on the other hand, gets her period every 19 days, which is far too often for her liking; this condition is called polymenorrhea (pol-ee-men-o-REE-a). These conditions are classified as abnormal uterine bleeding, or AUB. AUB also includes bleeding, or spotting, between periods and bleeding after menopause.

Eighty percent of women with menorrhagia have it because of a hormone imbalance or because they have fibroids (FY-broidz), which are abnormal growths in the uterus. Women with endometrial (en-do-ME-tree-al) cancer, infections of the vagina or cervix, small growths on the cervix or uterine wall (polyps), thyroid* conditions, or diseases of the liver*, kidney*, or bloodstream often experience menorrhagia.

*thyroid

(THY-roid) is a gland located in the lower part of the front of the neck. The thyroid produces hormones that regulate the body’s metabolism (me-TAB-o-liz-um), the processes the body uses to convert food into energy.

*liver

is a large organ located in the upper abdomen that has many functions, including storage and filtration of blood, secretion of bile, and participation in various metabolic (met-a-BOLL-ik) processes.

*kidney

is one of the pair of organs that filter blood and get rid of waste products and excess water as urine.

Menorraghia and other bleeding disorders that are caused by hormonal imbalances also are called dysfunctional uterine bleeding (DUB). Often, DUB occurs because of anovulation or when estrogen and progesterone are out of balance. Without proper hormonal cues, normal monthly shedding of the uterine lining does not occur, and the endometrium keeps building up. The abnormally thick endometrium eventually starts to break down and results in heavy and prolonged bleeding. DUB is common in teenagers, whose hormones have not yet been fine-tuned and who often do not ovulate regularly. Anovulation is also common in women about to go through menopause.

Painful periods

Lindas teacher was really beginning to get annoyed with her by midsemester. For four months in a row, Linda went home sick each time she started her period. Linda was not faking it; she went home to bed with a backache and severe cramps, only getting up when she thought she might have to throw up.

Linda suffers from dysmenorrhea (dis-men-o-REE-a), or painful periods. Almost every woman has this condition at some time in her life. The symptoms of dysmenorrhea range from mild, uncomfortable cramps to abdominal pain, a sore back, nausea, and vomiting. Linda has primary dysmenorrhea, which means painful periods with no underlying medical disease. This type of dysmenorrhea is very common, especially among teenagers. The symptoms are caused by the hormone prostaglandin, which is released by the cells that are being shed from the uterus.

Secondary dysmenorrhea is caused by medical conditions such as polyps*, fibroids, and narrowing of the cervix. One common cause is endometriosis (en-do-me-tree-O-sis). Endometriosis is a condition in which uterine tissue grows outside the uterus, and it affects both young and older women. Even though fragments of endometrial tissue, also called implants, are not in the uterus, they still respond to hormones just as the normal endometrial tissue does. Therefore, in response to estrogen and progesterone, the implants grow, break down, and bleed. Because there is no opening through which the blood can leave the body, the blood irritates the body, which can be very painful. Sometimes, the implants keep growing and form scar tissue or they act as an adhesive and stick organs together. Endometriosis can make it impossible for a woman to get pregnant, because implants may block the fallopian tubes or prevent the eggs from leaving the ovary. Endometriosis is found in 10 to 15 percent of 25- to 33-year-old women who actively are menstruating.

*polyps

(POL-ips) are protruding growths from a mucous (MU-kus) membrane.

Another type of pain that accompanies menstrual periods is caused by infections of the endometrium. This pain, seen in pelvic inflammatory disease (PID), needs rapid diagnosis and medical treatment.

Premenstrual syndrome

Every month, Stacy can tell her period is a week away by a trio of signs: her skin breaks out, her lower back begins to ache, and her breasts feel sore. Her friend Sonya experiences a different set of symptoms: she feels bloated, is incredibly tired, has bad headaches, and is depressed and grumpy.

Stacy and Sonya have premenstrual syndrome, or PMS, which is a set of symptoms that includes both physical and emotional complaints. Most women with PMS have a set of symptoms that occur each month at the same time. Fortunately, the symptoms disappear when the period begins.

Is There Such a Thing as Too Much Exercise?

How much estrogen a woman’s body produces appears to be linked to her level of body fat. Young gymnasts, ballerinas, and other athletes who regularly take part in strenuous exercise typically do not have much body fat and do not make much estrogen. If their hormone production is low enough, they might not get their first period until they are 16 or 17. Other young athletes who have normal periods for a while may develop amenorrhea when they resume strenuous exercise.

Because bone mass is linked to the level of estrogen in the body, some scientists suggest that even a few years of amenorrhea, especially during a girl’s teens, can have lasting effects on bone formation or contribute to excessive bone loss. Young athletes should see their doctor if they experience a menstrual disorder; diet and hormone therapy may fix the immediate problem and have a positive effect long into the future.

PMS is often referred to as a “phenomenon,” which indicates that it is still a controversial topic. Part of the problem with PMS is that no one knows for sure what causes it, but most scientists agree that it is linked to hormones. PMS symptoms appear during the second half of the menstrual cycle, after ovulation has taken place, when progesterone levels are highest.

Treatment for Menstrual Disorders

To determine if a woman has a menstrual disorder, doctors will take a medical history and ask questions about her menstrual cycle. Doctors need to know what has changed from past normal periods. A pelvic exam may also be necessary; doctors will examine the reproductive organs by feeling and pushing on the uterus through the abdomen and by feeling the vagina, cervix, uterus, fallopian tubes, and ovaries through the vaginal opening. This procedure is slightly uncomfortable but not painful, and it takes only 5 to 10 minutes. Blood tests also may be used to measure the levels of hormones in the body. In rare cases, a doctor will use ultrasonography (ul-tra-so-NOG-ra-fee), where sound waves are used to produce images of organs inside the body, and hysteroscopy (his-ter-OS-ko-pee) or laparascopy (lap-a-ROS-ko-pee), where instruments are inserted into the body through a small incision to take a direct look at the internal organs, to find out what is happening in a woman’s body.

Literal Meanings of Menstrual Terms

Many words used to describe menstruation and menstrual disorders come from Latin (“mensis” means month) and Greek. For example:

• Menarche, a girl’s first period, comes from “mensis” + “archaios” (from the beginning).
• Menopause, or the end of monthly periods, comes from “mensis” + “pausis” (to cease).
• Menorrhagia means heavy or prolonged bleeding and is derived from “mensis” + “rhegynein” (to burst forth).
• Menorrhea comes from “mensis” + “rhoia” (to flow) and means the normal flow of blood and tissue from the uterus during a menstrual period (also called menses and menstruation).
• The prefix “a” means not; amenorrhea is the cessation of menses. The prefix “dys” means bad or painful, and dysmenorrhea means painful periods. The prefix “oligo” means little or few; oligomenorrhea is having infrequent periods. “Poly” means many, and so polymenorrhea means periods that come too frequently.

For all menstrual disorders, treatment depends on the underlying cause. Therefore, it is important to see a doctor if anything seems to be wrong.

Hormonal imbalance

When a hormonal imbalance is the cause of a menstrual disorder, hormone therapy often helps menstrual cycles return to normal. Hormone therapy includes taking birth control pills, mixtures of estrogen and progesterone, or just progesterone.

Dysmenorrhea and PMS

Products such as ibuprofen (i-bu-PRO-fen) and naproxen (na-PROKS-en) suppress prostaglandin and are helpful in treating dysmenorrhea. Over-the-counter products to relieve menstrual cramps and bloating help some women with PMS. Birth control pills also reduce painful periods in some women, as does exercise.

Endometriosis and other conditions

For some women with endometriosis, the doctor can prescribe medicines to relieve symptoms. However, for women with severe endometriosis, surgery to remove implants may be necessary.

Severe menstrual disorders can be eliminated by destroying the endometrial tissue in the uterus or by hysterectomy (his-ter-EK-to-mee), which is the removal of uterus (and sometimes also the ovaries). This treatment is better for older women who are past childbearing years. This is not a treatment for younger women who want to have children.

For medical conditions, such as fibroids, polyps, or cancer, surgery and other treatments may be needed to correct the problem.

See also

Endometriosis

Infertility

Pelvic Inflammatory Disease (PID)

Pregnancy, Complications of

Resources

Books

Gillooly, Jessica B. Before She Gets Her Period: Talking with Your Daughter about Menstruation. Memphis, TN: Perspective Publishing, 1998.

Gravelle, Karen, Jennifer Gravelle, and Debbie Palen. The Period Book: Everything You Don’t Want to Ask (but Need to Know). New York: Walker and Co., 1996.

Organizations

American Society for Reproductive Medicine, 1209 Montgomery Highway, Birmingham, AL 35216-2809. Telephone 205-978-5000
http://www.asrm.org

The U.S. Food and Drug Administration has several websites that present information on menstruation,
http://www.fda.gov/opacom/7teens.html
http://www.fda.gov/opacom/catalog/ots_mens.html