Menstrual Disorders

Menstrual Disorders-

-Amenorrhea-

-Amenorrhea is the absence of menses.  It can be temporary, permanent, or occur intermittently

-Amenorrhea can result from dysfunction of he hypothalamus, pituitary, ovaries, uterus, or vagina

-Primary Amenorrhea is the absence of menarche by age 15

-Secondary amenorrhea is the absence of menses for 3 cycle intervals or six months women women were previously menstruating

-Etiologies of primary amenorrhea is usually the result of chromosomal abnormalities, hypothalamic hypogonadism, absence of uterus, cervix, or vagina (mullerian agenesis), transverse vaginal septum, imperforate hymen, and pituitary disease

-Pregnancy is the most common cause of secondary amenorrhea

-Common causes of secondary amenorrhea include disorders of the ovary, hypothalamus, pituitary, and uterus

-Lab work up should include pregnancy test, prolactin, FSH, TSH, DHEA-S

-High FSH concentrations suggest primary ovarian failure or insufficiency

-Further evaluation may look at assessment of estrogen status

-Treatment of women with secondary amenorrhea should be directed correcting the underlying pathology if possible and medical treatment to prevent complications such as estrogen replacement for prevention of osteoporosis


-Dysmenorrhea-

-Primary dysmenorrhea is characterized by recurrent, crampy lower abdominal pain occurring during menses and in the absence of demonstrable disease

-First line therapy includes heat packs and NSAIDS and/or estrogen progestin contraceptives

-For women who estrogen is not able to be used, NSAIDS only can be used as first line treatment

-Women who do not adequate pain relief with NSAIDS and/or estrogen contraceptive, secondary dysmenorrhea may need to be investigated

-Etiologies of secondary dysmenorrhea can include:  endometriosis, pelvic inflammatory disease, adhesions, pelvic congestion syndrome, adenomyosis, ovarian cancer, ovarian remnant syndrome, leiomyoma

-Treatment of secondary dysmenorrhea is targeted at determining cause and treating it if possible


-Premenstrual Syndrome-

-Premenstrual Syndrome references the physical and behavior symptoms that repetitively occur in the second half of the menstrual cycle and interfere with some aspects of a woman's life

-Premenstrual Dysphoric Disorder (PMDD) is symptoms of anger, irritability, and internal tension are prominent

-PMS is defined as at least one symptom associated with economic or social dysfunction that occurs five days before the onset of menses that occurs in at least 3 menstrual cycles

-Symptoms of PMS may be affective such as depression or angry outbursts, or physical such as breast pain or bloating

-Other potential causes of PMS symptoms include thyroid disorders, substance abuse, IBS, chronic fatigue symptoms, or migraines

-First line therapy for treatment is SSRI's such as fluoxetine, sertraline, paroxetine, or citalopram

-Other agents may help are oral contraceptives, xanax, or GnRH agonists


-Menopause-

-Natural menopause is permanent cessation of menstrual periods for at least 12 months without any other obvious cause

-The median age is 51.4 of menopause

-Menopause is a reflection of complete, or near complete ovarian follicle depletion

-Menopause before the age of 40 is considered to be abnormal and is referred to as primary ovarian insufficiency or premature ovarian failure

-Peri menopause begins usually 4 years before the onset of the final menstrual period.  It is accompanied by hot flashes, marked hormonal fluctuations, sleep disturbances, mood symptoms, and vaginal dryness

-Workup should include HCG, FSH, TSH, prolactin

-Estrogen is the gold standard for relief of menopausal symptoms.  Women with an intact uterus need a progestin in addition to estrogen to prevent endometrial hyperplasia

-Short term therapy is considered 2-3 years and generally not more than 5 years