Female Endocrinology

Menstrual Disorders

Menstrual disorders are problems related to a woman’s normal menstrual cycle. They are one of the most common reasons women visit their gynecologist.  Menstrual disorders and their symptoms can disrupt a woman’s daily life and can also affect her ability to become pregnant.

Types of menstrual disorders

Primary Dysmenorrhea

Painful menses without evidence of an organic lesion or cause. Pain is usually brief, and worse on the first day of menstruation.  Primary dysmenorrhea is usually seen in ovulatory menstrual cycles, typically occurs within five years of menarche, and improves with age. Over 50% of all post-pubescent women are affected and 5% are affected for 1-3 days each month. Most theories about the cause of primary dysmenorrhea center around excess prostaglandin around the endometrium cells. Prostaglandin is a powerful vaso-constrictive hormone that stimulates smooth muscle contraction of the myometrium, resulting in powerful uterine muscle contraction.

Treatment is usually aimed at prostaglandin inhibition or the suppression of cycles to inhibit its release. Non-specific measures like heat, mild analgesics, and exercise should be encouraged, but narcotics are not used.

Premenstrual Syndrome (PMS)

PMS is described as physical and emotional discomfort prior to menstruation, usually of unknown cause.

Symptoms include both emotional effects (depression, emotional liability) and physical effects (water retention, pain, breast tenderness). These symptoms are experienced in the luteal phase of the ovulatory cycle and become absent in the post-menstrual week.  Not all premenstrual changes are considered PMS. Symptoms should be severe enough to disrupt daily life and family interactions, and/or lead to alcohol or drug abuse, or suicidal thoughts.  Evaluation is usually made by carefully taken history.

Management of PMS depends on a responsive and cooperative patient who wants to get better. Sometimes exercise, vitamin B6, or antidepressants may be of value.

Abnormal Uterine Bleeding

Abnormal uterine bleeding is bleeding that is considered excessive in frequency, duration, or amount by an individual who has previous normal menstrual pattern. The bleeding is different from a woman’s normal menstrual cycle, and unusual for her age. Abnormal uterine bleeding is one of the most common gynecological health issues and can have many causes.

Pregnancy-related causes

  • Pregnancy or ectopic pregnancy
  • Miscarriage

Non-pregnancy-related causes

  • Hormonal imbalance
  • Problems linked to birth control methods
  • Infection of the uterus or cervix
  • Uterine fibroids or polyps
  • Problems with blood clotting
  • Cancer of the uterus, cervix, or vagina
  • Chronic medical conditions such as thyroid problems and diabetes
  • Endometrial hyperplasia.  Unopposed estrogen can lead to endometrial hyperplasia. Usually, a sample of the endometrial lining is recommended in those 35-years-old or older who have experienced abnormal uterine bleeding.


The absence of a normal monthly period or menstrual cycle. There are two major types of amenorrhea:

Primary amenorrhea

When a young woman has not had her first period by age 16. Possible causes include:

  • Failure of the ovaries, ovarian atresia.
  • Poorly formed reproductive organs.
  • Problems in the nervous system or the pituitary gland and failure to initiate menstrual cycle.
  • Extreme weight gain or weight loss
  • Long-term illness
  • Extreme exercise

Secondary amenorrhea

Defined when a woman who was previously menstruating stopped having menstrual bleeding for three months or more. This is the most common type of amenorrhea, where the endometrial lining does not shed synchronously and could occur in normal or pathological conditions.

  1. Physiological amenorrhea is an absence of menstruation during normal physiological conditions (e.g., pregnancy, lactation, and during menopause). Usually, these conditions are associated with physiological hormonal changes.
  2. Pathological amenorrhea is usually associated with anovulation and anovulatory cycles.
  • Conditions that interfere with the hypothalamic-pituitary axis
    • Pituitary adenoma – hyperprolactinemia
    • Stress and anxiety
    • Rapid weight loss
  • Exogenous sources of estrogen
    • Obesity: peripheral conversion of androgens to estrogen
    • Excess intake of estrogen
  • Defects in estrogen metabolism
    • thyroid and hepatic diseases

Take Home Message

  • Menstrual disorders can be associated with ovulatory and non-ovulatory cycles.


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Human Reproduction: A Clinical Approach Copyright © 2023 by Dr. Hala Bastawros, M.D is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.