Obstetrics and Gynecology/Menstrual Disorders

Definition

 * Pain on menstruation.

Epidemiology

 * Over 70% of women experience dysmenorrhea at some point.

Etiology, Risk Factors, and Pathophysiology
Primary dysmenorrhea
 * Results from production of prostaglandins within 48 hours of menstruation that stimulates the myometrial cells to contract.

Secondary dysmenorrhea Cervicitis
 * The result of a pathologic condition
 * Endometriosis, adenomyosis, cervical stenosis, vaginitis, psychological disturbance

Management

 * Birth control pill
 * GnRH analogues
 * NSAIDs (effective in 80% of women)

Definitions

 * Primary amenorrhea: failure to menstruate by 16 years of age with secondary sexual characteristics; failure to menstruate by 14 years of age without sexual characteristics; failure to mensturate with 2 years of sexual maturation.
 * Secondary amenorrhea: failure to menstruate for 6 months with formerly normal menses; oligomenorrhea with less than 9 cycles per year.

Etiology, Pathophysiology, and Risk Factors for Amenorrhea
Etiologies include
 * Müllerian agenesis (MRKH syndrome) in 10%
 * Androgen insensitivity in 5%
 * Imperforate hymen in 0.1%
 * Transverse vaginal septum in 1/80000
 * Ashermann's syndrome
 * Enzymatic deficiency
 * Premature ovarian failure
 * Pituitary tumours
 * FSH/LH mutations
 * Pituitary space-occupying lesions
 * Pituitary necrosis
 * Inflammatory/infiltrative pituitary disease
 * Pharmacologic prolactin stimulators
 * Stress induced amenorrhea
 * Isolated gonadotropin deficiency
 * Infections
 * Chronic disease
 * Hypothalamic tumours
 * Adrenal, thyroid, ovarian endocrine disease
 * Metastatic carcinoma

Clinical Presentation and Diagnostic Approach

 * Pregnancy must always be excluded.
 * Measure FSH and prolactin
 * If FSH is low or normal
 * Chronic anovulation
 * Anatomic defect (Müllerian agenesis)
 * If FSH is elevated
 * Ovarian failure
 * If prolactin is elevated
 * MRI head for prolactinoma


 * Karyotyping may be performed for the following indications
 * High FSH in a patient under 30 years of age
 * Height <147cm
 * Ambiguous genitalia (congenital adrenal hyperplasia)
 * Absent uterus

Management
Primary amenorrhea
 * Restore ovulation with estrogen and progesterone
 * Reassurance

Secondary amenorrhea
 * Treat the underlying cause