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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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Menstrual Disorders and Abnormal Vaginal Bleeding
Overview of Menstrual Disorders
Abnormal Uterine Bleeding (AUB)
Absence of Menstrual Periods
Menstrual Cramps
Pelvic Congestion Syndrome
Polycystic Ovary Syndrome (PCOS)
Premature Menopause
Premenstrual Syndrome (PMS)

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).

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
Amenorrhea	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
Premenstrual dysphoric disorder	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
Premenstrual syndrome (PMS)	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

Abnormal uterine bleeding
Absence of menstrual periods (amenorrhea)
Menstrual cramps (dysmenorrhea)
Premature menopause (primary ovarian insufficiency)
Premenstrual syndrome (PMS)

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