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Menstrual Disorders and Abnormal Vaginal Bleeding

December 28, 2010

Introduction

Complex interactions among hormones control the start of menstruation during puberty, the rhythms and duration of menstrual cycles during the reproductive years, and the end of menstruation at menopause.

  • Hormonal control of menstruation begins in the hypothalamus (the part of the brain that coordinates and controls hormonal activity).
  • The hypothalamus releases gonadotropin-releasing hormone in pulses.
  • Gonadotropin-releasing hormone stimulates the pituitary gland to produce two hormones called gonadotropins: luteinizing hormone and follicle-stimulating hormone.
  • Luteinizing hormone and follicle-stimulating hormone stimulate the ovaries.
  • The ovaries produce the female hormones estrogen and progesterone, which ultimately control menstruation.

Hormones produced by other glands, such as the adrenal glands and the thyroid gland, can also affect the functioning of the ovaries and menstruation.

During the reproductive years, vaginal bleeding may be abnormal when menstrual periods are too heavy or too light, last too long, occur too often, or are irregular. Any vaginal bleeding that occurs before puberty or after menopause is abnormal until proven otherwise.

Menstrual disorders include premenstrual syndrome, dysmenorrhea, dysfunctional uterine bleeding, and amenorrhea.

Amenorrhea

Amenorrhea is the absence of menstrual periods.

  • Menstrual periods may never start, or they may start, then stop.
  • Amenorrhea may result from various disorders or drugs that disrupt any part of the complex hormonal regulation of the menstrual cycle.
  • Symptoms, such as excess body hair, headaches, hot flashes, and vaginal dryness, may accompany amenorrhea depending on the cause.
  • The diagnosis is based on the woman’s menstrual history, but information about symptoms, a physical examination, and sometimes other tests are needed to identify the cause.
  • The disorder causing amenorrhea is treated if possible.
  • Adolescent girls who have never had a period may be given hormones to start periods.

Some women never go through puberty, so periods never start. This disorder is called primary amenorrhea. In other women, periods start at puberty, then stop. This disorder is called secondary amenorrhea. Amenorrhea is normal only before puberty, during pregnancy, while breastfeeding, and after menopause.

Amenorrhea can also be classified based on other features:

  • Whether an egg is released (ovulatory) or not (anovulatory)
  • Where the abnormality occurs, such as the hypothalamus (which controls the hormones that regulate menstrual cycles), pituitary gland (which produces hormones that stimulate the ovaries), or ovaries (which produce the hormones that ultimately control menstrual cycles)
  • What type of disorder is causing it—genetic, structural, hormonal, autoimmune, or something else

Most women have anovulatory amenorrhea (that is, no egg is released). Amenorrhea also may indicate pregnancy (the most common cause of secondary amenorrhea) or be the first symptom of a serious disorder and should be evaluated.

Causes

Malfunction of any part of the complex hormonal system that regulates the menstrual cycle can cause amenorrhea. This system includes the hypothalamus, pituitary, ovaries, adrenal glands, and thyroid gland. Malfunction of these organs can cause primary or secondary amenorrhea, depending on when malfunction occurs. Various disorders (including genetic, hormonal, and autoimmune disorders), infections, tumors, injuries, radiation therapy, and drugs can cause malfunction.

Some conditions, such as the following, cause only primary amenorrhea:

  • A birth defect of the uterus or fallopian tubes
  • A chromosomal disorder, such as Turner’s syndrome (in which the cells contain one X chromosome instead of the usual two)

In some genetic disorders, ovulation never begins, and puberty and secondary sexual characteristics do not develop normally.

Some conditions, such as the following, usually cause only secondary amenorrhea:

  • Polycystic ovary syndrome (characterized by irregular or no periods, obesity, high levels of male hormones, and often cysts in the ovaries)
  • Hydatidiform mole (a tumor that develops from an abnormal fertilized egg or the placenta)
  • Asherman’s syndrome (scarring of the lining of the uterus due to an infection or surgery)
  • Use of certain drugs (including hallucinogenic drugs, cocaine, opioids, chemotherapy drugs, antipsychotic drugs, antidepressants, and oral contraceptives) by women who have already started having menstrual periods

Some other disorders and stress due to internal or situational concerns can cause either type of amenorrhea. Stress interferes with the brain’s control (through hormones) of the ovaries. For example, exercising too much (or to excess) and eating disorders or underlnutrition (as in anorexia nervosa, starvation, or excessive dieting) can cause the brain to signal the pituitary gland to decrease its production of the hormones that stimulate the ovaries. As a result, the ovaries produce less estrogen, and periods never begin or they stop. Psychiatric disorders, such as depression or obsessive-compulsive disorder, can also cause this stress.

Symptoms

Amenorrhea may or may not be accompanied by other symptoms, depending on the cause. Such symptoms may include acne, excess body hair (hirsutism), deepening of the voice, headaches, visual disturbances, hot flashes, vaginal dryness, and decreased sex drive.

If amenorrhea lasts a long time, it can cause problems usually associated with menopause, such as decreased bone density (osteoporosis) and an increased risk of heart and blood vessel disorders.

Diagnosis

Primary amenorrhea is diagnosed when periods have not started by age 16. Girls who have no signs of puberty (such as breast development, pubic hair, and a growth spurt) by age 13 or who have not started having periods within 5 years of starting puberty are evaluated for possible problems. For example, doctors try to determine whether any other family members have had delayed puberty or a genetic disorder.

Secondary amenorrhea is diagnosed when a woman of reproductive age (who is not pregnant, breastfeeding, or menopausal) has had no menstrual periods for at least 6 months whether periods had been regular or irregular previously. Sometimes, secondary amenorrhea is diagnosed if such a woman has had no menstrual periods for only 3 months if periods had been regular previously. Doctors ask about use of drugs, exercise and eating habits, and other conditions that can cause amenorrhea.

In girls who have signs of puberty and in women of reproductive age, pregnancy tests are done to rule out pregnancy.

A physical examination can help doctors determine whether puberty has occurred or has occurred normally. Doctors examine the breasts and check for signs of puberty, such as pubic and underarm hair. They do a pelvic examination to determine whether the genital organs are developing normally and to check for abnormalities.

Other tests may be needed to confirm or identify the cause:

  • Hormone levels in the blood may be measured.
  • Magnetic resonance imaging (MRI) of the brain may be done to look for a pituitary tumor.
  • Computed tomography (CT), MRI, or ultrasonography may be used to look for a tumor in the ovaries or adrenal glands.
  • Hormones (estrogen and a progestin) may be given to try to trigger bleeding. The response may help doctors determine whether the abnormality is in the uterus or in the pituitary or hypothalamus.

Treatment

The underlying disorder is treated if possible. For example, a tumor is removed. Some disorders, such as Turner’s syndrome and other genetic disorders, cannot be cured.

If a girl’s periods have never started and all test results are normal, she is examined every 3 to 6 months to monitor the progression of puberty. A progestin and sometimes estrogen may be given to start her periods and to stimulate the development of secondary sexual characteristics, such as breasts.

Women who wish to become pregnant may be given hormones to induce release of an egg.

Problems associated with amenorrhea, such as osteoporosis or excess body hair, may require treatment.

Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding is abnormal bleeding resulting from changes in the hormonal control of menstruation.

  • Bleeding occurs frequently or irregularly, lasts longer, or is heavier.
  • This disorder is diagnosed when the physical examination, ultrasonography, and other tests have ruled out the usual causes of vaginal bleeding.
  • An endometrial biopsy is usually done.
  • The bleeding can usually be controlled with estrogen plus a progestin or sometimes with either alone.
  • If the biopsy detects abnormal cells, treatment involves high doses of a progestin and sometimes removal of the uterus.

Dysfunctional uterine bleeding occurs most commonly at the beginning and end of the reproductive years: 20% of cases occur in adolescent girls, and more than 50% occur in women older than 45. In about 90% of cases, the ovaries do not release an egg (ovulate). Thus, pregnancy is impossible.

Dysfunctional uterine bleeding commonly results when the level of estrogen remains high instead of decreasing as it normally does after the egg is released and not fertilized. The high estrogen level is not balanced by an appropriate level of progesterone. In such cases, no egg is released. As a result, the lining of the uterus (endometrium) continues to thicken (instead of breaking down and being shed normally as a menstrual period). This condition is called endometrial hyperplasia. The lining is then shed incompletely and irregularly, causing bleeding. Bleeding is irregular, prolonged, and sometimes heavy. This type of bleeding is common among women who have polycystic ovary syndrome and occurs in some women with endometriosis. A high estrogen level not balanced by progesterone increases the risk of endometrial cancer, even in young women.

Dysfunctional uterine bleeding may be an early sign of menopause.

Symptoms

Bleeding may differ from typical menstrual periods in the following ways:

  • Occur more frequently (less than 21 days apart — polymenorrhea)
  • Last longer or involve more blood loss than menses (more than 7 days or more than about 3 ounces — menorrhagia)
  • Occur frequently and irregularly between periods (metrorrhagia)

Bleeding during regular menstrual cycles may be abnormal, or bleeding may occur at unpredictable times. Some women have symptoms associated with menstrual periods, such as breast tenderness and bloating.

If bleeding continues, women may develop an iron deficiency and sometimes anemia.

Diagnosis

Dysfunctional uterine bleeding is suspected when bleeding occurs at irregular times or in excessive amounts. It is diagnosed when all other possible causes of vaginal bleeding have been excluded. These causes include abnormalities of the genital organs (including polycystic ovary syndrome), inflammation, blood clotting disorders, pregnancy, complications of pregnancy, and use of contraceptives or certain drugs.

To establish that bleeding is abnormal, doctors ask questions about the pattern of bleeding. To exclude other possible causes, they ask about other symptoms and possible causes (such as use of drugs, the presence of other disorders, fibroids, and complications during pregnancies). A physical examination is also done. A complete blood cell count can help doctors estimate how much blood has been lost and whether anemia is present.

Tests to check for possible causes may be done based on the findings during the interview and physical examination. For example, blood tests to determine how fast blood clots or to measure hormone levels may be done.

Transvaginal ultrasonography (using a thin probe inserted through the vagina and into the uterus) is often used to check for growths in the uterus and to determine whether the uterine lining is thickened.

If the risk of cancer of the uterine lining (endometrial cancer) is high, an endometrial biopsy is done before drug treatment is started. Risk is increased in women with the following:

  • Age 35 or older
  • Obesity
  • Polycystic ovary syndrome
  • High blood pressure
  • Diabetes
  • Bleeding that is persistent, irregular, or heavy despite treatment
  • Thickening of the uterine lining (detected by ultrasonography)
  • Inconclusive findings during ultrasonography

Most women with dysfunctional uterine bleeding have one or more of these conditions and thus require a biopsy.

Treatment

Treatment depends on how old the woman is, how heavy the bleeding is, whether the uterine lining is thickened, and whether the woman wishes to become pregnant. It focuses on controlling the bleeding and, if needed, preventing endometrial cancer.

When the uterine lining is thickened but its cells are normal, hormones may be used to control bleeding.

  • For heavy bleeding, a combination oral contraceptive (a birth control pill with estrogen and a progestin) may be used.
  • For very heavy bleeding, estrogen may be given intravenously until the bleeding stops. Sometimes a progestin is given by mouth at the same time or started 2 or 3 days later. Occasionally, bleeding is so heavy that fluids are given intravenously and a blood transfusion is needed. Very rarely, a catheter needs to be inserted into the uterus and inflated to put pressure on the bleeding vessels and thus stop the bleeding.

Bleeding usually stops in 12 to 24 hours. After bleeding stops, low doses of the oral contraceptive may then be prescribed for at least 3 months to prevent the bleeding from recurring.

Some women should not be treated with a combination oral contraceptive or estrogen. They include postmenopausal women and women with significant risk factors for a heart or blood vessel disorder. For these women, an intrauterine device (IUD) that contains a progestin may be used, or a progestin may be given alone by injection or by mouth. These treatments may also be used when those that include estrogen are ineffective.

If women wish to become pregnant and bleeding is not too heavy, they may be given clomiphene (a fertility drug) by mouth instead of hormones. It stimulates ovulation.

If the uterine lining remains thickened or the bleeding persists despite treatment with hormones, dilation and curettage (D and C) is usually needed. In this procedure, tissue from the uterine lining is removed by scraping. This procedure may reduce bleeding, but in some women, it causes scarring of the endometrium (Asherman’s syndrome), which can cause menstrual bleeding to stop (amenorrhea).

If the uterine lining contains abnormal cells (particularly in women who are older than 35 and who do not want to become pregnant), treatment begins with a high dose of a progestin. A biopsy is done after 3 to 6 months of treatment. If it detects abnormal cells, a hysterectomy is done because the abnormal cells may become cancerous. If women are postmenopausal, a progestin is not used. Hysterectomy is done.

Dysmenorrhea

Dysmenorrhea is pain in the lowest part of the abdomen (pelvis) during a menstrual period.

  • The cause is unidentified in most women.
  • Pain, usually crampy or sharp, starts a few days before a menstrual period and subsides after 2 or 3 days.
  • Doctors base the diagnosis on symptoms and results of a physical examination.
  • Nonsteroidal anti-inflammatory drugs or, if needed, low-dose birth control pills are used.

About three fourths of women have dysmenorrhea with no identifiable cause (primary dysmenorrhea). The rest have dysmenorrhea due to another condition (secondary dysmenorrhea).

Primary Dysmenorrhea: More than 50% of women may be affected, usually starting during adolescence. In about 5 to 15% of these women, primary dysmenorrhea is sometimes severe, interfering with daily activities and resulting in absence from school or work. Primary dysmenorrhea may become less severe with aging and after pregnancy.

In primary dysmenorrhea, the pain occurs only during menstrual cycles in which an egg is released. The pain is thought to result from prostaglandins released during menstruation. Prostaglandins are hormonelike substances that cause the uterus to contract, reduce the blood supply to the uterus, and increase the sensitivity of nerve endings in the uterus to pain. Women who have primary dysmenorrhea have higher levels of prostaglandins.

Secondary Dysmenorrhea: This type usually starts during adulthood. Common causes include the following:

  • Endometriosis: Patches of endometrial tissue—normally occurring only in the lining of the uterus (endometrium)—appear outside the uterus.
  • Fibroids: Noncancerous tumors composed of muscle and fibrous tissue grow in the uterus.
  • Adenomyosis: The uterus enlarges when endometrial tissue grows into the muscular wall of the uterus.
  • Pelvic congestion syndrome: Blood accumulates in the veins of the pelvis because these veins have widened and become convoluted.
  • Pelvic infection: Symptoms can worsen premenstrually or menstrually.
  • Cervical stenosis: The passageway through the cervix (cervical canal) may be narrow at birth or may become narrow when polyps are removed or a precancerous condition (dysplasia) or cancer of the cervix is treated. In a few women, cervical stenosis causes pain during menstrual periods, as menstrual blood attempts to pass through the cervix but is partly blocked.
Adenomyosis: Noncancerous Growth of the Uterus
In adenomyosis, glandular tissue from the lining of the uterus (endometrium) grows into the muscular wall of the uterus. The uterus becomes enlarged, sometimes doubling or tripling in size.This common disorder causes symptoms in only a small percentage of women, usually those between the ages of 35 and 50. It is more common among women who have had children. The cause is unknown. 

Symptoms include heavy and painful periods, bleeding between periods, vague pain in the pelvic area, and a feeling of pressure on the bladder and rectum. Sometimes sexual intercourse is painful.

Doctors suspect adenomyosis when they do a pelvic examination and discover that the uterus is enlarged, round, and softer than normal. Pelvic ultrasonography or magnetic resonance imaging (MRI) helps confirm the diagnosis. Sometimes when adenomyosis causes abnormal bleeding, a biopsy is done.

Usually, no treatment is effective, although oral contraceptives and gonadotropin-releasing hormone analogues (such as leuprolide or goserelin) may be tried. Analgesics may be taken for pain. In some women, a hysterectomy may be done.

Symptoms

Pain occurs in the lowest part of the abdomen (pelvis) and may extend to the lower back or legs. The pain is usually crampy or sharp and comes and goes, but it may be a dull, constant ache. Usually, the pain starts 1 to 3 days before or during the menstrual period, peaks after 24 hours, and subsides after 2 or 3 days.

Other common symptoms include headache, nausea, constipation, diarrhea, and an urge to urinate frequently. Occasionally, vomiting occurs. Premenstrual irritability, nervousness, depression, and abdominal bloating may persist during part or all of the menstrual period. Sometimes the menstrual blood contains clumps of tissue.

Diagnosis

Diagnosis is based on symptoms and the results of a physical examination. To identify possible causes (such as fibroids), ultrasonography may be done. Also, doctors may examine the abdominal cavity using a viewing tube (laparoscope) inserted through a small incision just below the navel. They may examine the interior of the uterus using a similar tube (hysteroscope) inserted through the vagina and cervix. Other procedures may include magnetic resonance imaging (MRI) and removal of a tissue sample from the inside of the uterus for analysis (endometrial biopsy).

Treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs) usually relieve pain effectively. NSAIDs may be more effective if started 1 or 2 days before a menstrual period begins and continued for 1 or 2 days after it begins. Nausea and vomiting usually disappear without treatment as the pain subsides. Applying heat to the lower abdomen, getting enough rest and sleep, and exercising regularly may also help relieve symptoms.

If the pain continues to interfere with daily activities, oral contraceptives that contain estrogen in a low dose plus a progestin may be prescribed to suppress the release of eggs from the ovaries (ovulation).

When dysmenorrhea results from another disorder, that disorder is treated if possible. A narrow cervical canal can be widened surgically. However, this operation usually relieves the pain only temporarily. If needed, fibroids or misplaced endometrial tissue (due to endometriosis) is surgically removed.

When other treatments are ineffective and the pain is severe, the nerves to the uterus may be cut surgically. However, this operation occasionally injures other pelvic organs, such as the ureters. Alternatively, hypnosis or acupuncture may be tried.

What Is Pelvic Congestion Syndrome?
Sometimes pain that occurs before or during menstrual periods results from a problem with veins in the pelvis. The veins may widen (dilate) and become convoluted, and blood accumulates in them. The result is varicose veins in the pelvis—a disorder called pelvic congestion syndrome. Pain, sometimes debilitating, can result. Estrogen may contribute because it causes some of the veins supplying the ovaries and uterus to also dilate, so that blood can accumulate in these veins as well. Up to 15% of women of reproductive age have varicose veins in their pelvis, but not all of them have symptoms.Typically, the pain is dull and aching, but it may be sharp or throbbing. It is worse at the end of the day (after a woman has been sitting or standing a long time) and is relieved when she lies down. The pain is also worse during or after sexual intercourse. It is often accompanied by low back pain, aches in the legs, abnormal menstrual bleeding, and an occasional clear or watery vaginal discharge. Some women have fatigue, mood swings, headaches, and abdominal bloating. 

Doctors may suspect pelvic congestion syndrome when a woman has pelvic pain but a pelvic examination does not detect inflammation or another abnormality. Ultrasonography can help doctors confirm the diagnosis. Alternatively, the veins can be viewed with a viewing tube inserted through a small incision just below the navel in a procedure called laparoscopy.

Nonsteroidal anti-inflammatory drugs (NSAIDs) usually relieve the pain.

Polycystic Ovary Syndrome

Polycystic ovary syndrome involves disruption of the menstrual cycle and a tendency to have high levels of male hormones (androgens).

  • Women are typically obese and have irregular or no menstrual periods, and in some, the voice deepens, breast size decreases, and acne and excess body hair develop.
  • Doctors often base the diagnosis on symptoms, but blood tests to measure hormone levels and ultrasonography may also be done.
  • Exercise, weight loss, and estrogen plus a progestin or a progestin alone may help reduce symptoms (including excess body hair) and normalize hormone levels.
  • If women wish to become pregnant, losing weight and taking clomiphene, sometimes with metformin, may stimulate release of an egg.

Polycystic ovary syndrome affects about 5 to 10% of women. In the United States, it is the most common cause of . It gets its name from the many fluid-filled sacs (cysts) that often develop in the ovaries, causing them to enlarge.

A common cause is excess production of luteinizing hormone by the pituitary gland. The excess luteinizing hormone increases the production of male hormones (androgens). High levels of male hormones increases the risk of metabolic syndrome (with high blood pressure, high cholesterol levels, and resistance to the effects of insulin). If male hormone levels remain high, the risk of diabetes, heart and blood vessel disorders, and high blood pressure is increased. Also, some of the male hormones may be converted to estrogen, increasing estrogen levels. Not enough progesterone is produced to balance the increased level of estrogen. If this situation continues a long time, the lining of the uterus (endometrium) may become extremely thickened (a condition called endometrial hyperplasia). Also, the risk of cancer of the lining of the uterus (endometrial cancer) may be increased.

In many women, the body’s cells resist the effects of insulin (called insulin resistance or sometimes prediabetes). Insulin helps sugar (glucose) pass into cells so that they can use it for energy. When cells resist its effects, sugar accumulates in the blood, and the pancreas produces more insulin to try to lower sugar levels in the blood. If insulin resistance becomes moderate or severe, diabetes is diagnosed.

Symptoms

Symptoms typically develop during puberty and worsen with time. Symptoms vary from woman to woman.

In some women, menstrual periods do not start at puberty. Irregular vaginal bleeding or amenorrhea is typical. Thus, these women are not releasing an egg from the ovaries (ovulating). These women also develop symptoms related to the high levels of male hormones—a process called masculinization or virilization. Symptoms include acne, a deepened voice, a decrease in breast size, and an increase in muscle size and in body hair (hirsutism). Hair grows as it does in men (for example, on the chest and face) and may thin at the temples.

Most women are obese. Producing too much insulin contributes to weight gain or makes losing weight difficult. Excess insulin may also cause skin in the armpits, on the nape of the neck, and in skinfolds to become dark and thick (a disorder called acanthosis nigricans).

Diagnosis

Often, the diagnosis is based on symptoms. Blood tests to measure levels of hormones such as follicle-stimulating hormone and male hormones are done. Ultrasonography is done to see whether the ovaries contain many cysts and to check for a tumor in an ovary or adrenal gland. These tumors can produce excess male hormones and thus cause the same symptoms as polycystic ovary syndrome.

In women with this syndrome, blood pressure and usually blood sugar levels are measured to check for metabolic syndrome. Tests to check Cushing’s syndrome are also done. Often, a biopsy of the uterine lining (endometrial biopsy) is done to make sure no cancer is present.

Treatment

The choice of treatment depends on the type and severity of symptoms, the woman’s age, and her plans regarding pregnancy.

If insulin levels are high, lowering them may help. Exercising (at least 30 minutes a day) and reducing consumption of carbohydrates (in breads, pasta, potatoes, and sweets) can help lower insulin levels. In some women, weight loss lowers insulin levels enough that ovulation can begin. Weight loss may help reduce hair growth and the risk of thickening of the uterine lining.

Metformin, which is used to treat type 2 diabetes, may be used to increase sensitivity to insulin so the body does not have to make as much insulin. This drug may help women lose weight, and ovulation and menstrual periods may resume. If women take metformin and do not wish to become pregnant, they should use birth control.

If women wish to become pregnant, losing weight may help. If not, clomiphene is tried. This drug stimulates ovulation. If clomiphene is ineffective and the woman has insulin resistance, metformin may help because lowering insulin levels may trigger ovulation. If these drugs are not effective, other fertility drugs may be tried. They include follicle-stimulating hormone (to stimulate the ovaries), a gonadotropin-releasing hormone agonist (to stimulate the release of follicle-stimulating hormone), and human chorionic gonadotropin (to trigger ovulation).

Women who do not wish to become pregnant may take a progestin by mouth or a combination oral contraceptive (a birth control pill that contains estrogen and a progestin). Either treatment may reduce the risk of endometrial cancer due to the high estrogen level and help lower the levels of male hormones. However, oral contraceptives are not given to women who have reached menopause or who have other significant risk factors for heart or blood vessel disorders.

Increased body hair can be bleached or removed by electrolysis, plucking, waxing, hair-removing liquids or creams (depilatories), or laser. No drug treatment for removing excess hair is ideal or completely effective. The following may help:

  • Eflornithine cream may help remove unwanted facial hair.
  • Oral contraceptives may help, but they must be taken for several months before any effect, which is often slight, can be seen.
  • Spironolactone, a drug that blocks the production and action of male hormones, can reduce the amount of unwanted body hair. Side effects include increased urine production and low blood pressure (sometimes causing fainting). Spironolactone may not be safe for a developing fetus, so sexually active women taking the drug are advised to use effective birth control methods.
  • Cyproterone, a strong progestin that blocks the action of male hormones, reduces the amount of unwanted body hair in 50 to 75% of affected women. It is used in many countries but is not approved in the United States.

Gonadotropin-releasing hormone agonists and antagonists are being studied as treatment for unwanted body hair. Both types of drugs inhibit the production of sex hormones by the ovaries. But both can cause bone loss and lead to osteoporosis.

Premenstrual Syndrome

Premenstrual syndrome (PMS) is a group of physical and psychologic symptoms that start several days before and usually end a few hours after a menstrual period begins.

  • PMS includes any combination of the following: becoming irritable, anxious, moody, or depressed or having headaches or sore, swollen breasts.
  • Doctors base the diagnosis on symptoms, which are usually tracked in a monthly calendar.
  • Consuming less sugar, salt, and caffeine and exercising may help relieve symptoms, as does taking certain supplements, pain relievers, birth control pills (sometimes), or antidepressants.

Because so many symptoms, such as a bad mood, irritability, bloating, and breast tenderness, have been ascribed to PMS, defining and identifying PMS can be difficult. PMS affects 20 to 50% of women. About 5% of women of reproductive age have a severe form of PMS called premenstrual dysphoric disorder.

PMS may occur partly because estrogen and progesterone levels fluctuate during the menstrual cycle. Some women are more sensitive to these fluctuations. Also, in some women with PMS, progesterone may be broken down differently. Progesterone is usually broken down into two components that have opposite effects on mood. Women with PMS may produce less of the component that tends to reduce anxiety and more of the component that tends to increase anxiety.

The fluctuations in estrogen and progesterone may affect other hormones, such as aldosterone, which helps regulate salt and water balance. Excess aldosterone can cause fluid retention and bloating.

Symptoms

The type and intensity of symptoms vary from woman to woman and from month to month in the same woman. The various physical and psychologic symptoms of PMS can temporarily upset a woman’s life.

Symptoms may begin a few hours up to about 10 days before a menstrual period, and they often disappear completely a few hours after the period begins. Women who are approaching menopause may have symptoms that persist through and after the menstrual period. The symptoms of PMS are may be followed each month by a painful period (dysmenorrhea), particularly in teenagers.

Other disorders may worsen while PMS symptoms are occurring. They include the following:

  • Seizure disorders, with more seizures than usual
  • Connective tissue disorders (such as lupus or rheumatoid arthritis), with flare-ups
  • Respiratory disorders (such as allergies and congestion of the nose and airways)

In premenstrual dysphoric disorder, premenstrual symptoms are so severe that they interfere with work, social activities, or relationships.

Symptoms That Can Occur in Premenstrual Syndrome
  • Physical
    • Awareness of heartbeats (palpitations)
    • Backache
    • Bloating
    • Breast fullness and pain
    • Changes in appetite and cravings for certain foods
    • Constipation
    • Cramps, heaviness, or pressure in the lower abdomen
    • Dizziness, including vertigo
    • Easy bruising
    • Fainting
    • Fatigue
    • Headaches
    • Hot flashes
    • Insomnia, including difficulty falling or staying asleep at night
    • Joint and muscle pain
    • Lack of energy
    • Nausea and vomiting
    • Pins-and-needles sensations in the hands and feet
    • Skin problems, such as acne and localized scratch dermatitis
    • Swelling of hands and feet
    • Weight gain
  • Psychologic
    • Agitation
    • Anxiety
    • Confusion
    • Crying spells
    • Depression
    • Difficulty concentrating
    • Emotional hypersensitivity
    • Irritability
    • Forgetfulness or memory loss
    • Mood swings
    • Nervousness
    • Short temper
    • Social withdrawal

Diagnosis

The diagnosis is based on symptoms. To identify PMS, doctors ask a woman to keep a daily record of her symptoms. This record helps the woman be aware of changes in her body and moods and helps doctors identify any regular symptoms and determine what treatment is best. Premenstrual dysphoric disorder cannot be diagnosed until a woman has recorded her symptoms for at least two menstrual cycles. Doctors can distinguish premenstrual syndrome and premenstrual dysphoric disorder from mood disorders, such as depression, because the symptoms disappear soon after the menstrual period begins.

Treatment

Women can do the following to help relieve symptoms:

  • Get enough rest and sleep
  • Exercise regularly, which may help lessen bloating as well as irritability, anxiety, and insomnia
  • Use stress reduction techniques (meditation or relaxation exercises)
  • Avoid stressful activities
  • Consume more protein and calcium and less sugar and caffeine (including that in chocolate)
  • Consume less salt, which often reduces fluid retention and relieves bloating
  • Take certain supplements: vitamin B complex (especially vitamin B6), calcium (1,000 milligrams a day), vitamin D, and magnesium

Women should talk to their doctor before they take supplements, especially vitamin B6, which may be harmful if taken in high doses. Nerve damage is possible with as little as 200 milligrams a day.

Doctors may prescribe diuretics (which help the kidneys eliminate salt and water from the body) to help reduce fluid retention.

Taking nonsteroidal anti-inflammatory drugs may help relieve headaches, pain due to abdominal cramps, and joint pain. Taking combination oral contraceptives (birth control pills that contain estrogen and a progestin) reduces pain, breast tenderness, and changes in appetite in some women but worsens these symptoms in a few. Taking oral contraceptives that contain only a progestin does not help.

Women who have more severe symptoms may benefit from taking fluoxetine, paroxetine, or sertraline, which are antidepressants. These drugs are used to prevent symptoms, and to be effective, they should be taken before symptoms begin. Taking these drugs after symptoms begin usually does not relieve symptoms as well as taking them prior to onset. They are most effective in reducing irritability, depression, and some other symptoms of PMS. Doctors may ask a woman to continue keeping a record of her symptoms so that they can judge the effectiveness of treatment.

Women who have premenstrual dysphoric disorder may benefit from taking antidepressants such as fluoxetine, paroxetine, or sertraline. Taking a gonadotropin-releasing hormone (GnRH) analogue (such as leuprolide or goserelin), given by injection, may control symptoms. This drug is a synthetic form of a hormone produced by the body. GnRH analogues cause the body to produce less estrogen and progesterone. Thus, these drugs are used with estrogen plus a progestin, taken in a low dose by mouth or patch.

LEARN MORE Women’s Health: Surviving PMS
Women’s Health Connection Heavy Periods
Source: Merck Manual Home Edition
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