Chapter 9: Menstruation-Related Disorders

LEARNING OBJECTIVES

1. Define the following common menstruation-related conditions: primary and secondary dysmenorrhea, amenorrhea, menorrhagia, and oligomenorrhea.

2. Explain the pathophysiologic mechanisms, clinical presentation, and diagnosis of primary and secondary dysmenorrhea, amenorrhea, menorrhagia, and oligomenorrhea.

3. Compare nonpharmacologic and pharmacologic treatment options and their place in therapy for primary dysmenorrhea, amenorrhea, menorrhagia, and oligomenorrhea.

4. Devise a treatment plan for patients with primary dysmenorrhea, amenorrhea, menorrhagia, and oligomenorrhea, including evaluation, treatment, and monitoring.

INTRODUCTION

Menstrual disorders, particularly abnormal uterine bleeding, are common gynecologic disorders. Menstrual disorders are generally viewed as disorders of regularity, duration, frequency, and amount of menstrual blood flow. Abnormal menses are typically described using terminologies in Table 9-1. Menstrual disorders are clinically important because they may affect quality of life, increase health care utilization, cause fertility concerns, and warrant gynecologic operations such as hysterectomies. This chapter will focus on the evaluation and management of the most common menstruation-related disorders: primary dysmenorrhea, with an overview of secondary dysmenorrhea, amenorrhea, menorrhagia, and oligomenorrhea.

Dysmenorrhea is defined as painful menstruation of uterine origin and is commonly divided into two categories based on the pathophysiology. Primary dysmenorrhea is painful menstruation that typically begins during adolescence with ovulatory cycles and is not due to any pelvic disease. It is distinguished from secondary dysmenorrhea, which is uncommon during adolescence and results from pelvic organ pathology. Common causes of secondary dysmenorrhea include endometriosis, uterine fibroids, adenomyosis (uterine thickening that occurs when endometrial tissue, which normally lines the uterus, moves into the outer muscular walls of the uterus causing painful and/or profuse menses), obstructive vaginal or uterine congenital anomalies, and use of intrauterine contraceptive devices.^1,2

Primary dysmenorrhea is by far the most common gynecologic complaint amongst menstruating girls and women. The prevalence is difficult to determine because of different definitions of the condition and different groups of patients studied. However, estimates vary from 60% to 91%.³ The prevalence of primary dysmenorrhea is highest in the 20- to 24-year-old age group and decreases progressively thereafter.⁴

Dysmenorrhea pain that is severe enough to limit daily activities has been reported as occurring in 16% to 29% of women.³ Primary dysmenorrhea is the leading cause of recurrent short-term absenteeism from school amongst adolescent girls in the United States.^5,6 In several longitudinal studies in women under the age of 30, the rates of absenteeism ranged from 34% ...