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Overview of Menstrual Disorders

By JoAnn V. Pinkerton, MD, Professor of Obstetrics and Gynecology and Division Director, Midlife Health Center;Executive Director, University of Virginia Health System;The North American Menopause Society

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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 (which is usually defined as beginning 12 months after a woman's last period).

The hormonal interactions that control menstruation occur in the following sequence:

  • The hypothalamus (a part of the brain that coordinates and controls hormonal activity) 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 affect the functioning of the ovaries and menstruation.

Changes During the Menstrual Cycle

The menstrual cycle is regulated by the complex interaction of hormones: luteinizing hormone, follicle-stimulating hormone, and the female sex hormones estrogen and progesterone.

The menstrual cycle has three phases:

  • Follicular (before release of the egg)

  • Ovulatory (egg release)

  • Luteal (after egg release)

The menstrual cycle begins with menstrual bleeding (menstruation), which marks the first day of the follicular phase.

When the follicular phasebegins, levels of estrogen and progesterone are low. As a result, the top layers of the thickened lining of the uterus (endometrium) break down and are shed, and menstrual bleeding occurs. About this time, the follicle-stimulating hormone level increases slightly, stimulating the development of several follicles in the ovaries. Each follicle contains an egg. Later in this phase, as the follicle-stimulating hormone level decreases, only one follicle continues to develop. This follicle produces estrogen.

The ovulatory phase begins with a surge in luteinizing hormone and follicle-stimulating hormone levels. Luteinizing hormone stimulates egg release (ovulation), which usually occurs 16 to 32 hours after the surge begins. The estrogen level peaks during the surge, and the progesteronelevel starts to increase.

During the luteal phase,luteinizing hormone and follicle-stimulating hormone levels decrease. The ruptured follicle closes after releasing the egg and forms a corpus luteum, which produces progesterone. During most of this phase, the estrogen level is high. Progesterone and estrogencause the lining of the uterus to thicken more, to prepare for possible fertilization. If the egg is not fertilized, the corpus luteum degenerates and no longer produces progesterone, the estrogenlevel decreases, the top layers of the lining break down and are shed, and menstrual bleeding occurs (the start of a new menstrual cycle).

Deciphering Medical Terms for Menstrual Disorders*

Term

Description

No periods

Dysmenorrhea

Menstrual cramps or painful periods

Hypomenorrhea

Unusually light periods

Menometrorrhagia

Heavy bleeding during menstrual periods and bleeding that occurs frequently and irregularly between periods

Menorrhagia (hypermenorrhea)

Unusually long and/or heavy periods

Metrorrhagia

Bleeding that occurs frequently and irregularly between periods

Oligomenorrhea

Unusually infrequent periods

Polymenorrhea

Unusually frequent periods

Postmenopausal bleeding

Bleeding that occurs after menopause

Severe psychologic symptoms that occur before the start of a period, end when or shortly after the period starts, and interfere with daily activities and/or relationships

Physical and psychologic symptoms that occur before the start of a period

Primary amenorrhea

No periods ever starting (at puberty)

Secondary amenorrhea

Periods that have stopped

*Breaking the words into their components helps decipher them: a = no; dys = painful (or abnormal); hypo =deficient (or below normal); men = month; metro = uterus; oligo = few or scanty; poly = many or much; post = after; pre =before; rhagia = to burst forth; rhea = flow.

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 considered abnormal until proven otherwise. Most causes of abnormal vaginal bleeding are not serious.

Menstrual disorders include

Some disorders that are related to the reproductive organs but not specifically to the menstrual cycle cause some of the same symptoms as menstrual disorders. These disorders include

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