Menstrual disorders include:
Treatment options for menstrual disorders include:
The levonorgestrel-releasing intrauterine system (LNG-IUS) works better for improving quality of life for women with heavy bleeding than medical treatments with oral estrogen-progesterone contraceptives or progesterone injections, suggests a 2013 study published in the New England Journal of Medicine.
Menstrual disorders are problems that affect a woman's normal menstrual cycle. They include painful cramps during bleeding, abnormally heavy bleeding, or not having any bleeding.
Menstruation occurs during the years between puberty and menopause. Menstruation, also called a "period," is the monthly flow of blood from the uterus through the cervix and out through the vagina.
The organs and structures in the female reproductive system include:
The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.
The menstrual cycle is regulated by the complex surge and fluctuations in many different reproductive hormones. These hormones work together to prepare a women's body for pregnancy. The hypothalamus (an area in the brain) and the pituitary gland control six important hormones:
The menstrual cycle begins with the first day of bleeding. The menstrual cycle is divided into three phases:
Typical Menstrual Cycle
Typical No. of Days
Follicular (Proliferative) Phase
Cycle Days 1 to 6: Beginning of menstruation to end of blood flow.
Estrogen and progesterone start out at their lowest levels.
FSH levels rise to stimulate maturity of follicles. Ovaries start producing estrogen and levels rise, while progesterone levels remains low.
Cycle Days 7 to 13: The endometrium thickens to prepare for the egg implantation.
Cycle Day 14:
Surge in LH. Largest follicle bursts and releases egg into fallopian tube.
Luteal (Secretory) Phase, also known as the Premenstrual Phase
Cycle Days 15 to 28:
Ruptured follicle develops into corpus luteum, which produces progesterone. Progesterone and estrogen stimulate blanket of blood vessels to prepare for egg implantation.
If fertilization occurs:
Fertilized egg attaches to blanket of blood vessels that supplies nutrients for the developing placenta. Corpus luteum continues to produce estrogen and progesterone.
If fertilization does not occur:
Corpus luteum deteriorates. Estrogen and progesterone levels drop. The blood vessel lining sloughs off and menstruation begins.
There are several types of menstrual disorders. Problems can range from heavy, painful periods to no periods at all. There are many variations in menstrual patterns, but in general women should be concerned when periods come fewer than 21 days or more than 3 months apart, or if they last more than 10 days. Such events may indicate ovulation problems or other medical conditions.
Dysmenorrhea is severe, frequent cramping during menstruation. Pain occurs in the lower abdomen but can spread to the lower back and thighs. Dysmenorrhea is usually referred to as primary or secondary:
During a normal menstrual cycle, the average woman loses about 1 ounce (30 mL) of blood and changes her tampons or pads around 3 to 6 times per day.
With menorrhagia, menstrual flow lasts longer and is heavier than normal. The bleeding occurs at regular intervals (during periods). It usually lasts more than 7 days and women lose an excessive amount of blood. Clot formation is common. Menorrhagia is often accompanied by dysmenorrhea because passing large clots can cause painful cramping.
Menorrhagia is a type of abnormal uterine bleeding. Other types of abnormal bleeding are:
Amenorrhea is the absence of menstruation. There are two categories: primary amenorrhea and secondary amenorrhea. These terms refer to the time when menstruation stops:
When girls first menstruate they often do not have regular cycles for several years. Even healthy cycles in adult women can vary by a few days from month to month. Periods may occur every 3 weeks in some women, and every 5 weeks in others. Flow also varies and can be heavy or light. Skipping a period and then having a heavy flow may occur; this is most likely due to missed ovulation rather than a miscarriage.
Premenstrual syndrome (PMS) is a set of physical, emotional, and behavioral symptoms that occur during the last week of the luteal phase (a week before menstruation) in most cycles. The symptoms typically do not start until at least day 13 in the cycle, and resolve within 4 days after bleeding begins.
Women may begin to have premenstrual syndrome symptoms at any time during their reproductive years, but it usually occurs when they are in their late 20s to early 40s. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle.
Many different factors can trigger menstrual disorders, including hormone imbalances, genetic factors, clotting disorders, and pelvic diseases.
Primary dysmenorrhea is caused by prostaglandins, hormone-like substances that are produced in the uterus and cause the uterine muscle to contract. Prostaglandins also play a role in the heavy bleeding that causes dysmenorrhea.
Secondary dysmenorrhea can be caused by a number of medical conditions. Common causes of secondary dysmenorrhea include:
Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body, causing pain and irregular bleeding.
There are many possible causes for heavy bleeding:
Fibroid tumors may not need to be removed if they are not causing pain, bleeding excessively, or growing rapidly.
Normal causes of skipped or irregular periods include pregnancy, breastfeeding, hormonal contraception, and perimenopause. Skipped periods are also common during adolescence, when it may take a while before ovulation occurs regularly. Consistently absent periods may be due to the following factors:
If the ovaries produce too much androgen (hormones such as testosterone) a woman may develop male characteristics. This ovarian imbalance can be caused by tumors in the ovaries or adrenal glands, or polycystic ovarian disease. Virilization may include growth of excess body and facial hair, amenorrhea (loss of menstrual period) and changes in body contour.
Age plays a key role in menstrual disorders. Girls who start menstruating at age 11 or younger are at higher risk for severe pain, longer periods, and longer menstrual cycles. Adolescents may develop amenorrhea before their ovulation cycles become regular.
Women who are approaching menopause (perimenopause) may also skip periods. Occasional episodes of heavy bleeding are also common as women approach menopause.
Other risk factors include:
Menorrhagia (heavy menstrual bleeding) is the most common cause of anemia (reduction in red blood cells) in premenopausal women. A blood loss of more than 80mL (around 3 tablespoons) per menstrual cycle can eventually lead to anemia. Most cases of anemia are mild. Nevertheless, even mild-to-moderate anemia can reduce oxygen transport in the blood, causing symptoms such as fatigue, lightheadedness, and pale skin. Severe anemia that is not treated can lead to heart problems.
Amenorrhea (absent or irregular menstrual periods) caused by reduced estrogen levels is linked to osteopenia (loss of bone density) and osteoporosis (more severe bone loss that increases fracture risk). Because bone growth is at its peak in adolescence and young adulthood, losing bone density at that time is very dangerous and early diagnosis and treatment is essential for long-term health.
Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue, and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency, or advanced age. Regular weight-bearing exercise and strength training, and calcium and vitamin D supplements, can reduce and even reverse loss of bone density.
Some conditions associated with heavy bleeding, such as ovulation abnormalities, fibroids, or endometriosis, can contribute to infertility. Many conditions that cause amenorrhea, such as ovulation abnormalities and polycystic ovary syndrome, can also cause infertility. Irregular periods from any cause may make it more difficult to conceive. Sometimes treating the underlying condition can restore fertility. In other cases, specific fertility treatments that use assisted reproductive technologies may be needed.
Menstrual disorders, particularly pain and heavy bleeding, can affect school and work productivity and social activities.
Your medical history can help a health care provider determine whether a menstrual problem is caused by another medical condition. For example, non-menstrual conditions that may cause abdominal pain include appendicitis, urinary tract infections, ectopic pregnancy, and irritable bowel syndrome. Endometriosis and uterine fibroids may cause heavy bleeding and pain.
Your provider may ask questions concerning:
Blood tests can help rule out other conditions that cause menstrual disorders. For example, your provider may test thyroid function to make sure that low thyroid (hypothyroidism) is not present. Blood tests can also check follicle-stimulating hormone, estrogen, and prolactin levels.
Women who have menorrhagia (heavy bleeding) may get tests for bleeding disorders. If women are losing a lot of blood, they should also get tested for anemia.
Imaging techniques are often used to detect certain conditions that may be causing menstrual disorders. Imaging can help diagnose fibroids, endometriosis, or structural abnormalities of the reproductive organs.
Transvaginal sonohysterography uses ultrasound along with a probe (transducer) placed in the vagina. Sometimes saline (salt water) is injected into the uterus to enhance visualization.
Hysteroscopy is done in the office setting and requires no incisions. The procedure uses a slender flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber-optic light source and a tiny camera in the tube allow the health care provider to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.
Hysteroscopy is non-invasive, but many women find the procedure painful. The use of an anesthetic spray such as lidocaine can help prevent pain from this procedure. Other complications include excessive fluid absorption, infection, and uterine perforation. Hysteroscopy is also performed as part of surgical procedures.
The procedure is used to take samples of the tissue, and to relieve heavy bleeding in some instances.
Dietary adjustments, starting about 14 days before a period may help some women with certain mild menstrual disorders, such as cramping. The general guidelines for a healthy diet apply to everyone; they include eating plenty of whole grains, fresh fruits and vegetables, and avoiding saturated fats and commercial junk foods.
Limiting salt (sodium) may help reduce bloating. Limiting caffeine, sugar, and alcohol intake may also be beneficial.
Increasing intake of vitamin C rich foods can enhance absorption of non-heme iron.
There have been a number of reported cases of serious and even lethal side effects from herbal products. You should check with your health care provider before using any herbal remedies or dietary supplements.
Studies have not generally found herbal or natural remedies to be any more effective than placebos (sugar pills) for reducing menstrual disorders. Natural remedies promoted for menstrual symptoms include:
There are a number of different medicines prescribed for menstrual disorders.
Among the most effective NSAIDs for menstrual disorders are ibuprofen (Advil, Motrin, Midol PMS, generic) and naproxen (Aleve, generic), which are both available over-the-counter, and mefenamic acid (Ponstel, generic), which requires a doctor's prescription. Long-term daily use of any NSAID can increase the risk for gastrointestinal bleeding and ulcers, so it is best to just use these drugs for a few days during the menstrual cycle.
An ulcer is a crater-like lesion on the skin or mucous membrane.
Oral contraceptives (OCs), commonly called birth control pills or "the Pill," contain combinations of an estrogen and a progesterone (in a synthetic form called progestin).
The estrogen compound used in most combination OCs is estradiol. There are many different progestins, but common types include levonorgestrol, drospirenone, and norgestrol. Natazia, an OC that contains estradiol and the progesterone dienogest, is specifically approved for treatment of heavy bleeding.
OCs are often used to regulate periods in women with menstrual disorders, including menorrhagia (heavy bleeding), dysmenorrhea (severe pain), and amenorrhea (absence of periods). Oral contraceptives are as effective for treating pelvic pain from endometriosis as the more potent gonadotropin releasing hormone agonists. They also protect against ovarian and endometrial cancers.
Standard OCs usually comes in a 28-pill pack with 21 days of "active" (hormone) pills and 7 days of "inactive" (placebo) pills. Extended-cycle (also called "continuous-use" or "continuous-dosing") oral contraceptives aim to reduce or eliminate monthly menstrual periods. These OCs contain a combination of estradiol and the progestin levonorgestrel, but they use extending dosing of active pills with 81 to 84 days of active pills followed by 7 days of inactive or low-dose pills. Some types of continuous-dosing OCs use only active pills, which are taken 365 days a year
However, all OCs can increase the risk for migraine, stroke, heart attack, and blood clots. The risk is highest for women who smoke, who are over age 35, or who have a history of heart disease risk factors (such as high blood pressure or diabetes) or past cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for the heart-related complications associated with these pills. Some types of combination OCs contain progestins, such as drospirenone, which have a much higher risk for causing blood clots than levonorgestrel.
Progestins (synthetic progesterone) are used by women with irregular or skipped periods to restore regular cycles. They also reduce heavy bleeding and menstrual pain, and may protect against uterine and ovarian cancers. Progestin-only contraceptives may be a good option for women who are not candidates for estrogen-containing OCs, such as smokers over the age of 35.
Progestins can be delivered in various forms.
Many doctors recommend the LNG-IUS as a first-line treatment for severe heavy menstrual bleeding, particularly for women who may face hysterectomy (removal of uterus) or conservative surgery such as endometrial ablation (destruction of the endometrial lining). This device is considered a good long-term option, especially for women who may desire future pregnancies. Research also indicates that women who choose the LNG-IUS are highly satisfied with the results and experience an improved quality of life equal to those who choose surgery.
The LNG-IUS remains in place in the uterus and releases the progestin levonorgestrel for up to 5 years. Progestin released by an IUD mainly affects the uterus and cervix, and so it causes fewer widespread side effects than progestin pills do.
After the LNG-IUS is inserted, heaver periods may occur during the first 3 to 6 months as the lining of the uterus is shed. This shedding may also cause irregular periods and light bleeding ("spotting") between menstrual cycles. Eventually, the LNG-IUS results in a shorter period, with little or no blood flow. For many women, the LNG-IUS completely stops menstrual periods.
Common side effects may include cramping, acne, back pain, breast tenderness, headache, mood changes, and nausea. The LNG-IUS may increase the risk for ovarian cysts, but such cysts usually cause no symptoms and resolve on their own. Women who have a history of pelvic inflammatory disease or who have had a serious pelvic infection should not use the LNG-IUS. Because of the risks associated with pelvic infection, health care providers recommend that women who use the LNG-IUS be in a stable monogamous relationship. The LNG-IUS does not protect against sexually transmitted diseases.
Weight gain can be a problem, particularly in women who are already overweight. Women should not use Depo-Provera if they have a history of liver disease, blood clots, stroke, or cancer of the reproductive organs. Depo-Provera should not be used for longer than 2 years because it can cause loss of bone density.
Gonadotropin releasing hormone (GnRH) agonists are sometimes used to treat severe menorrhagia. GnRH agonists block the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce estrogen.
GnRH agonists include the implant goserelin (Zoladex), a monthly injection of leuprolide (Lupron Depot, generic), and the nasal spray nafarelin (Synarel). Such drugs may be used alone or in preparation for procedures used to destroy the uterine lining. They are not generally suitable for long-term use.
Commonly reported side effects, which can be severe in some women, include menopausal-like symptoms. These symptoms include hot flashes, night sweats, changes in the vagina, weight change, and depression. The side effects vary in intensity depending on the GnRH agonist. They may be more intense with leuprolide and persist after the drug has been stopped.
The most important concern is possible osteoporosis from estrogen loss. Women should not take these drugs for more than 6 months. Add-back therapy, which provides doses of estrogen and progestin that are high enough to maintain bone density but are too low to offset the beneficial effects of the GnRH agonist, may be used.
GnRH treatments may increase the risk for birth defects. Women who are taking GnRH agonists should use non-hormonal birth control methods, such as the diaphragm, cervical cap, or condoms.
Danazol (Danocrine, generic) is a synthetic substance that resembles a male hormone. It suppresses estrogen, and therefore menstruation, and is occasionally used (sometimes in combination with an oral contraceptive) to help prevent heavy bleeding. It is not suitable for long-term use, and due to its masculinizing side effects it is only used in rare cases. GnRH agonists have largely replaced the use of danazol.
Adverse side effects include facial hair, deepening of the voice, weight gain, acne, and reduced breast size. Danazol may also increase the risk for unhealthy cholesterol levels and it may cause birth defects.
Tranexamic acid (Lysteda) is a newer medication for treating heavy menstrual bleeding and the first non-hormonal drug for menorrhagia treatment. Tranexamic acid is given as a pill. It is an anti-fibrinolytic drug that helps blood to clot. The FDA warns that use of this medication by women who take hormonal contraceptives may increase the risk of blood clots, stroke, or heart attacks. This drug should not be taken by women who have a history of blood clots.
Women with heavy menstrual bleeding, painful cramps, or both have surgical options available to them. Most procedures eliminate or significantly affect the possibility for childbearing, however. Hysterectomy removes the entire uterus while endometrial ablation destroys the uterine lining.
The levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena), is increasingly being used instead of surgery to treat heavy menstrual bleeding. Studies have found the LNG-IUS works just as well as ablation. Women should be sure to ask their doctors about all medical options before undergoing surgical procedures.
In endometrial ablation, the entire lining of the uterus (the endometrium) is removed or destroyed. For most women, this procedure stops the monthly menstrual flow. In some women, menstrual flow is not stopped but is significantly reduced.
Endometrial ablation is not appropriate for women who:
A main concern of endometrial ablation is that it may delay or make it more difficult to diagnose uterine cancer in the future. (Postmenopausal bleeding or irregular vaginal bleeding can be warning signs of uterine cancer.) Women who have endometrial ablation still have a uterus and cervix, and should continue to have regular Pap smears and pelvic exams.
The newer procedures can be performed either in an operating room or a doctor's office. They include:
Nearly all women have reduced menstrual flow after endometrial ablation, and nearly half of women have their periods stop. Some women, however, may continue to have bleeding problems and ultimately decide to have second ablation procedure or a hysterectomy.
Hysterectomy is the surgical removal of the uterus.
Heavy bleeding, often from fibroids, and pelvic pain are the reasons for many hysterectomies. However, with newer medical and surgical treatments available, hysterectomies are performed less often than in the past.
In its support, hysterectomy, unlike drug treatments and less invasive procedures, cures menorrhagia completely, and most women are satisfied with the procedure. Less invasive hysterectomy procedures are also improving recovery rates and increasing satisfaction afterward. Still, any woman who is uncertain about a recommendation for a hysterectomy to treat fibroids or heavy bleeding should certainly seek a second opinion.
Some women who have hysterectomies have their ovaries removed along with their uterus. Surgical removal of the ovaries is called an oophorectomy. A hysterectomy does not cause menopause but removal of both ovaries (bilateral oophorectomy) does cause immediate menopause.
Doctors may recommend hormone therapy for certain women. Hormone therapy for a woman who has her uterus uses a combination of estrogen and progestin because estrogen alone increases the risk for endometrial (uterine) cancer. However, women who have had their uteruses removed do not have this risk and can take estrogen alone, without the progestin.
Some evidence suggests that surgically cutting the pain-conducting nerve fibers leading from the uterus diminishes the pain from dysmenorrhea. Two procedures, laparascopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy (LPSN), can block such nerves.
Some small studies have shown benefits from these procedures, but stronger evidence is needed before they can be recommended for women with severe primary dysmenorrhea or the chronic pelvic pain associated with endometriosis. Many insurance companies consider these procedures experimental and will not pay for them.
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Reviewed By: Irina Burd, MD, PhD, Associate Professor of Gynecology and Obstetrics at Johns Hopkins University School of Medicine, Baltimore, MD. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team. Author: Julia Mongo, MS.