Menstrual Problems

Menstrual disorders encompass a wide range of issues related to the menstrual cycle, including heavy bleeding (menorrhagia), painful periods (dysmenorrhea), irregular periods, no periods (amenorrhea), and premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). Each condition has its unique features, and the approach to diagnosis, differential diagnosis, and management can be quite detailed.

Causes

  1. Hormonal Imbalances: Fluctuations in estrogen and progesterone can disrupt the menstrual cycle.
  2. Polycystic Ovary Syndrome (PCOS): A common endocrine disorder causing irregular menstrual cycles.
  3. Thyroid Disorders: Both hypothyroidism and hyperthyroidism can affect menstruation.
  4. Uterine Fibroids or Polyps: Benign growths in the uterus can lead to heavy or prolonged menstrual bleeding.
  5. Uterine Hyperplasia or Adenomyosis: Abnormal thickening of the uterine lining
  6. Endometriosis: Where tissue similar to the lining inside the uterus grows outside it, causing painful periods.
  7. Pelvic Inflammatory Disease (PID): An infection of the female reproductive organs that can affect menstruation.
  8. Stress and Lifestyle Factors: High stress levels, significant weight loss or gain, and excessive exercise can disrupt periods.
  9. Contraceptives: Hormonal contraceptives can cause irregular bleeding.
  10. Coagulations Disorders: Like von Willebrand disease or thrombocytopenia.

Diagnosis

  • History:
    • Menstrual History: Frequency, regularity, duration, and volume of bleeding.
    • Associated Symptoms: Pain, mood changes, systemic symptoms like weight change, or hirsutism.
    • Medical History: Thyroid disorders, clotting disorders, or other chronic illnesses.
    • Sexual History: Pregnancy risk, sexually transmitted infections.
    • Medication and Drug History: Including the use of hormonal contraception or anticoagulant medications.
    • Family History: Bleeding disorders or hormonal issues.
  • Examination
    • Vital Signs: To check for signs of anemia or thyroid dysfunction.
    • Abdominal and Pelvic Examination: To look for signs of masses, enlargement of organs, or tenderness.
    • Body Mass Index (BMI): As extremes of weight can affect menstrual cycles.
  • Investigations
    • Pregnancy Test: To exclude pregnancy.
    • Blood Tests: FBC for anemia, hormone levels (FSH, LH, prolactin, TSH, free T4), and androgen levels if PCOS is suspected.
    • Ultrasound: To assess the uterus and ovaries.
    • Endometrial Biopsy: In certain cases, to exclude hyperplasia or malignancy, especially for women over 40 or those with risk factors for endometrial cancer.

Differential Diagnosis

Menstrual disorders may be due to a variety of conditions, and the differential diagnosis could include:

  • Dysfunctional Uterine Bleeding: Often a diagnosis of exclusion when no organic cause is found.
  • Polycystic Ovary Syndrome (PCOS): Can cause irregular or absent periods and may be associated with signs of hyperandrogenism.
  • Thyroid Disorders: Both hypothyroidism and hyperthyroidism can cause menstrual irregularities.
  • Coagulopathies: Such as von Willebrand disease, can present with menorrhagia.
  • Endometriosis: Can cause dysmenorrhea and heavy menstrual bleeding.
  • Fibroids and Polyps: Benign growths that can affect bleeding and cause pain.
  • Pregnancy-Related Issues: Ectopic pregnancy or miscarriage can present with abnormal bleeding.
  • Premature Ovarian Insufficiency: Leads to irregular periods or amenorrhea in women under 40.
  • Pituitary Adenomas: Can cause amenorrhea, particularly prolactin-secreting adenomas.

Management

The management of menstrual disorders is tailored to the specific diagnosis and the severity of the symptoms, and it may include:

  • Dysmenorrhea
    • NSAIDs: First-line treatment for pain relief.
    • Hormonal Contraceptives: To regulate or suppress the menstrual cycle.
    • Lifestyle Changes: Regular exercise and dietary modifications.
  • Menorrhagia/Dysfunctional Uterine Bleeding
    • Hormonal Therapies:
      • Oral contraceptives,
      • Progestins ie norethisterone 5mg TDS
      • Mirena levonorgestrel-releasing intrauterine system
    • NSAIDS: For pain and bleeding
    • Tranexamic Acid: To reduce bleeding.
    • Surgical Options: Endometrial ablation, uterine artery embolization, or hysterectomy for refractory cases.
  • Amenorrhea
    • Estrogen Therapy: For hypoestrogenic states.
    • Dopamine Agonists: For hyperprolactinemia (ie bromocriptine)
    • Clomiphene or Gonadotropins: For anovulation if fertility is desired.
  • PMS/PMDD
    • Lifestyle Modifications: Exercise and a healthy diet.
    • SSRIs: Particularly for PMDD, often effective even when used only in the luteal phase.
    • Hormonal Contraceptives: Some may find relief with these.
    • GnRH Agonists: For severe cases refractory to other treatments.
  • PCOS
    • Weight Loss: First-line treatment for overweight women.
    • Metformin: May help restore normal menstruation and ovulation.
    • Hormonal Contraceptives: To regulate menstrual cycles and manage hyperandrogenism.

For all menstrual disorders, education and counseling are essential parts of management. Women should understand the nature of their disorder, treatment options, expected outcomes, and when to seek further medical attention. It’s also important to address the emotional and psychological impacts of menstrual disorders, as these can significantly affect a woman’s quality of life. Referral to a gynecologist is warranted when initial treatments are ineffective or when a more serious underlying condition is suspected.