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.
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.
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.
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, 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
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.
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
- Pelvic inflammatory disease (PID)
- An IUD
- A uterine, ovarian, bowel or bladder tumor
- Uterine polyps
- Inflammatory bowel disease
- Scarring or adhesions from earlier surgery
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
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.
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.
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.
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.
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.
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%.
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.
The prognosis for all menstrual irregularities is good once treatment is initiated.
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.
Prevention includes certain dietary supplements and vitamins described above. Exercise may also help.
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.
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.
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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〉.