Menstrual disorders

Menstrual cycle disorders can reduce women's ability to work for a long time, accompanied by a deterioration in reproductive function (miscarriage, infertility), both immediate (bleeding, anemia, asthenia) and remote (endometrial cancer, ovarian cancer, breast cancer) consequences and complications.

Causes of menstrual cycle disorders

Menstrual cycle disorders are mainly secondary in nature, i.e. they are a consequence of genital (damage to the regulatory system and target organs of the reproductive system) and extragenital pathology, the impact of various unfavorable factors on the system of neurohumoral regulation of reproductive function.

The leading etiological factors of menstrual cycle disorders include:

• disturbances in the restructuring of the hypothalamic-pituitary system during critical periods of development of the female body, especially during puberty;
• diseases of the female genital organs (regulatory, purulent-inflammatory, tumor, trauma, developmental defects);
• extragenital diseases (endocrinopathies, chronic infections, tuberculosis, diseases of the cardiovascular system, hematopoiesis, gastrointestinal tract and liver, metabolic diseases, neuropsychiatric diseases and stress);
• occupational hazards and environmental problems (exposure to chemicals, microwave fields, radioactive radiation, intoxication, sudden climate change, etc.);
• violation of the diet and work regime (obesity, starvation, hypovitaminosis, physical overwork, etc.);
• genetic diseases.

Menstrual cycle disorders can also be caused by other reasons:

• Hormonal imbalance. A decrease in progesterone levels in the body is often the cause of hormonal imbalance in the body, which leads to menstrual irregularities.
• Stressful situations. Menstrual cycle disorders caused by stress are often accompanied by irritability, headaches, and general weakness.
• Genetic predisposition. If your grandmother or mother had problems of this kind, it is quite possible that you inherited this disorder.
• Lack of vitamins and minerals in the body, exhaustion of the body, painful thinness.
• Climate change.
• Taking any medications may have a side effect in the form of menstrual irregularities.
• Infectious diseases of the genitourinary system.
• Alcohol abuse, smoking.

It should be emphasized that by the time the patient seeks medical attention, the effect of the etiologic factor may have disappeared, but its effect will remain.

[ 1 ], [ 2 ]

Phases of the menstrual cycle

Follicular phase

The menstrual phase includes the menstrual period itself, which can last from two to six days in total. The first day of menstruation is considered the beginning of the cycle. When the follicular phase begins, menstrual flow stops and hormones of the hypothalamus-pituitary system begin to be actively synthesized. Follicles grow and develop, the ovaries produce estrogens that stimulate the renewal of the endometrium and prepare the uterus to receive the egg. This period lasts about fourteen days and ends with the release of hormones into the blood that inhibit the activity of follicle stimulating hormones.

Ovulatory phase

During this period, the mature egg leaves the follicle. This is due to a rapid increase in the level of luteotropins. Then it penetrates the fallopian tubes, where fertilization occurs. If fertilization does not occur, the egg dies within twenty-four hours. On average, the ovulatory period occurs on the 14th day of the menstrual cycle (if the cycle lasts twenty-eight days). Minor deviations are considered normal.

Luteinizing phase

The luteinizing phase is the last phase of the menstrual cycle and usually lasts about sixteen days. During this period, the corpus luteum appears in the follicle, producing progesterone, which promotes the attachment of the fertilized egg to the uterine wall. If pregnancy does not occur, the corpus luteum ceases to function, the amount of estrogen and progesterone decreases, which leads to the rejection of the epithelial layer, as a result of increased synthesis of prostaglandins. This completes the menstrual cycle.

The processes in the ovary that occur during the menstrual cycle can be represented as follows: menstruation → maturation of the follicle → ovulation → production of the corpus luteum → completion of the functioning of the corpus luteum.

Regulation of the menstrual cycle

The cerebral cortex, the hypothalamus-pituitary-ovarian system, the uterus, vagina, and fallopian tubes participate in the regulation of the menstrual cycle. Before you begin to normalize the menstrual cycle, you should visit a gynecologist and take all the necessary tests. In case of concomitant inflammatory processes and infectious pathologies, antibiotic treatment and physiotherapy may be prescribed. To strengthen the immune system, it is necessary to take vitamin and mineral complexes, have a balanced diet, and give up bad habits.

Menstrual cycle failure

Menstrual cycle failure is most often found in adolescents in the first year or two from the onset of menstruation, in women in the postpartum period (up to the end of lactation), and is also one of the main signs of the onset of menopause and the end of the ability to fertilize. If the menstrual cycle failure is not associated with any of these reasons, then such a disorder can be provoked by infectious pathologies of the female genital organs, stressful situations, hormonal imbalances in the body.

When talking about menstrual cycle failure, the duration and intensity of menstrual flow should also be taken into account. Thus, excessively heavy flow may indicate the development of a tumor in the uterine cavity, and may also be the result of the negative impact of an intrauterine device. A sharp decrease in the content released during menstruation, as well as a change in the color of the discharge, may indicate the development of a disease such as endometriosis. Any abnormal bloody discharge from the genital tract may be a sign of an ectopic pregnancy, so if any irregularities in the monthly cycle occur, it is strongly recommended to consult a doctor.

Delayed menstrual cycle

If your period has not started within five days from the expected date, it is considered a delay in the menstrual cycle. One of the reasons for the absence of menstruation is pregnancy, so a pregnancy test is the first thing to do if your period is delayed. If the test is negative, you should look for the cause in diseases that may have affected the menstrual cycle and caused its delay. Among them are gynecological diseases, as well as endocrine, cardiovascular diseases, neurological disorders, infectious pathologies, hormonal changes, vitamin deficiency, injuries, stress, overexertion, etc. In adolescence, a delay in the menstrual cycle in the first year or two from the onset of menstruation is a very common phenomenon, since the hormonal background at this age is not yet stable enough.

[ 3 ], [ 4 ]

Symptoms of menstrual irregularities

Hypomenaprual syndrome is a menstrual cycle disorder characterized by a decrease in the volume and duration of menstruation until it stops. It occurs both with a normal and a disrupted cycle.

The following forms of hypomenstrual syndrome are distinguished:

• Hypomenorrhea - scanty and short periods.
• Oligomenorrhea - delays in menstruation from 2 to 4 months.
• Opsomenorrhea - delays in menstruation from 4 to 6 months.
• Amenorrhea is an extreme form of hypomenstrual syndrome, which is the absence of menstruation for 6 months or more during the reproductive period.

Physiological amenorrhea occurs in girls before puberty, in pregnant and breastfeeding women, and in postmenopausal women.

Pathological amenorrhea is divided into primary, when menstruation does not occur in women over 16 years of age, and secondary, when the menstrual cycle is not restored within 6 months in a previously menstruating woman.

Different types of amenorrhea differ in the causes and the level of damage to the reproductive system.

Primary amenorrhea

Menstrual cycle disorder, which is a deficiency of factors and mechanisms that ensure the initiation of menstrual function. Examination is required for 16-year-old (and possibly 14-year-old) girls who do not have breast development by this age. In girls with normal menstrual cycle, the mammary gland should have an unchanged structure, and the regulatory mechanisms (hypothalamic-pituitary axis) should not be impaired.

Secondary amenorrhea

The diagnosis is made when there is no menstruation for more than 6 months (except pregnancy). As a rule, this condition is caused by disorders of the hypothalamic-pituitary axis; the ovaries and endometrium are rarely affected.

Oligomenorrhea

This menstrual cycle disorder occurs in women with irregular sexual life, when regular ovulation does not occur. In the reproductive period of life, the cause is most often polycystic ovary syndrome.

Menorrhagia

Heavy bleeding.

Dysmenorrhea

Painful periods. 50% of women in the UK report painful periods, 12% report very painful periods.

Primary dysmenorrhea is painful menstruation without an organic cause. This menstrual irregularity occurs after the onset of the ovarian cycle shortly after menarche; the pain is cramping, radiating to the lower back and groin, and is most severe during the first 1–2 days of the cycle. Excessive production of prostaglandins stimulates excessive contraction of the uterus, which is accompanied by ischemic pain. Prostaglandin inhibitors, such as mefenamic acid, at a dose of 500 mg orally every 8 hours, reduce prostaglandin production and, as a consequence, pain. Pain can be relieved by suppressing ovulation with combined contraceptives (dysmenorrhea may be a reason for prescribing contraceptives). Pain is somewhat reduced after childbirth by stretching the cervical canal, but surgical stretching may be a cause of cervical insufficiency and is not currently used as a treatment.

Secondary dysmenorrhea is caused by pelvic pathology, such as endometriosis, chronic sepsis; occurs at a later age. It is more constant, is observed throughout the entire period and is often combined with deep dyspareunia. The best treatment is to treat the underlying disease. Dysmenorrhea increases with the use of intrauterine contraceptives (IUDs).

[ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ]

Intermenstrual bleeding

Menstrual irregularity that occurs in response to mid-cycle estrogen production. Other causes: cervical polyp, ectropion, carcinoma; vaginitis; hormonal contraceptives (local); IUD; pregnancy complications.

Bleeding after coitus

Causes: cervical trauma, polyps, cervical cancer; vaginitis of various etiologies.

[ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ]

Bleeding after menopause

Menstrual irregularity that occurs 6 months after the last menstruation. Until proven otherwise, endometrial carcinoma is considered the cause. Other causes: vaginitis (often atrophic); foreign bodies, such as pessaries; cervical or vulvar cancer; endometrial or cervical polyps; withdrawal of estrogens (during hormone replacement therapy for ovarian tumors). The patient may confuse vaginal bleeding with rectal bleeding.

[ 15 ], [ 16 ], [ 17 ], [ 18 ]

Pain syndrome with preserved cycle

Pain syndrome with a preserved cycle - cyclic pain observed during ovulation, the luteal phase of the menstrual cycle and at the beginning of menstruation, can be caused by a number of pathological conditions.

Ovarian hyperstimulation syndrome is a pain syndrome that occurs during hormonal drug stimulation of the ovaries, which in some cases requires emergency care.

Types of menstrual dysfunction

The degree of menstrual cycle disturbance is determined by the level and depth of disturbances in the neurohormonal regulation of the menstrual cycle, as well as changes in the target organs of the reproductive system.

There are various classifications of menstrual cycle disorders: by the level of damage to the reproductive system (CNS - hypothalamus - pituitary gland - ovaries - target organs), by etiological factors, by clinical picture.

Menstrual cycle disorders are divided into the following groups:

• Algomenorrhea, or painful periods, is more common than other disorders, can occur at any age and is observed in about half of women. With algomenorrhea, pain during menstruation is combined with headache, general weakness, nausea, and sometimes vomiting. The pain syndrome usually lasts from several hours to two days.
• Dysmenorrhea. This disorder is characterized by instability of the menstrual cycle – menstruation can be significantly delayed or start earlier than expected.
• Oligomenorrhea is a menstrual cycle disorder characterized by a reduction in the duration of menstruation to two or less days. Menstrual flow is usually scanty, the duration of the intermenstrual period can be over thirty-five days.
• Amenorrhea is the absence of menstruation for several cycles.

Treatment of menstrual irregularities

Treatment of menstrual cycle disorders is varied. It can be conservative, surgical or mixed. Often the surgical stage is followed by treatment with sex hormones, which plays a secondary, corrective role. This treatment can be either radical, pathogenetic in nature, completely restoring the menstrual and reproductive function of the body, or play a palliative, substitutive role, creating an artificial illusion of cyclic changes in the body.

Correction of organic disorders of the target organs of the reproductive system is usually achieved surgically. Hormonal therapy is used here only as an auxiliary means, for example, after removal of adhesions of the uterine cavity. In these patients, oral contraceptives (OC) are most often used in the form of cyclic courses over 3-4 months.

Surgical removal of the gonads containing male germ cells is mandatory in patients with gonadal dysgenesis with a 46XY karyotype due to the risk of malignancy. Further treatment is carried out jointly with an endocrinologist.

Hormone replacement therapy (HRT) with sex hormones is prescribed after the patient's growth has ceased (bone growth zones have closed) with estrogens only at the first stage: ethinyl estradiol (microfollin) 1 tablet/day for 20 days with a 10-day break, or estradiol dipropionate 0.1% solution 1 ml intramuscularly once every 3 days - 7 injections. After the appearance of menstrual-like discharge, they switch to combined therapy with estrogens and gestagens: microfollin 1 tablet/day for 18 days, then norethisterone (norcolut), duphaston, lutenil 2-3 tablets/day for 7 days. Since this therapy is carried out for a long time, for years, breaks of 2-3 months are allowed after 3-4 treatment cycles. Similar treatment can be carried out with oral contraceptives with a high level of estrogen component - 0.05 mg ethinyl estradiol (non-ovlon), or with HRT drugs for climacteric disorders (femoston, cycloprogynova, divina).

Tumors of the pituitary-hypothalamic region (sellar and suprasellar) are subject to surgical removal or undergo radiation (proton) therapy followed by replacement therapy with sex hormones or dopamine analogues.

Hormone replacement therapy is indicated for patients with hyperplasia and tumors of the ovaries and adrenal glands with increased production of sex steroids of various origins, in isolation or as a postoperative stage of treatment, as well as in postovariectomy syndrome.

The greatest difficulty in the therapy of various forms of amenorrhea is primary ovarian damage (ovarian amenorrhea). Therapy for the genetic form (premature ovarian failure syndrome) is exclusively palliative (cyclic HRT with sex hormones). Until recently, a similar regimen was proposed for ovarian amenorrhea of autoimmune genesis (ovarian resistance syndrome). The incidence of autoimmune oophoritis, according to various authors, ranges from 18 to 70%. In this case, antibodies to ovarian tissue are detected not only in hypergonadotropic, but also in 30% of patients with normogonadotropic amenorrhea. Currently, to relieve the autoimmune block, it is recommended to use corticosteroids: prednisolone 80-100 mg/day (dexamethasone 8-10 mg/day) - 3 days, then 20 mg/day (2 mg/day) - 2 months.

The same role can be played by antigonadotropic drugs (gonadotropin-releasing hormone agonists), prescribed for up to 8 months. Later, if there is an interest in pregnancy, ovulation stimulants (clostilbegyt) are prescribed. In patients with hypergonadotropic amenorrhea, the effectiveness of such therapy is extremely low. To prevent estrogen deficiency syndrome, they are prescribed HRT drugs for climacteric disorders (femoston, cycloprogynova, divina, trisequence, etc.).

Diseases of the most important endocrine glands of the body, which secondarily lead to sexual dysfunction, require treatment primarily by an endocrinologist. Sex hormone therapy is often not required or is of an auxiliary nature. At the same time, in some cases, their parallel administration allows for faster and more stable compensation of the underlying disease (diabetes mellitus). On the other hand, the use of ovarian TFD allows, at the appropriate stage of treatment, to select the optimal dose of the drug for pathogenetic action both for the restoration of menstrual and reproductive function and for compensation of the underlying disease.

Therapy of milder stages of hypomenstrual syndrome than amenorrhea is closely related to the degree of hormonal insufficiency of the menstrual cycle. The following groups of drugs are used for conservative hormonal therapy of menstrual dysfunction.

Menstrual Cycle Irregularities: Treatment

In case of menstrual cycle disorders associated with hormonal imbalance and progesterone deficiency, the drug cyclodinone is used. The drug is taken once a day in the morning - one tablet or forty drops at a time, without chewing and with water. The general course of treatment is 3 months. In the treatment of various menstrual cycle disorders, such as algomenorrhea, amenorrhea, dysmenorrhea, as well as during menopause, the drug remens is used. It promotes the normal functioning of the hypothalamus-pituitary-ovarian system and balances the hormonal balance. On the first and second days, the drug is taken 10 drops or one tablet eight times a day, and starting from the third day - 10 drops or one tablet three times a day. The duration of treatment is three months.

Modern drugs for medicinal correction of menstrual dysfunction

Group of drugs	Preparation
Gestagens	Progesterone, 17-hydroxyproteosterone capronate (17-OPC), uterogestan, duphaston, norethistron, norcolut, acetomepregenol, orgametril
Estrogens	Estradiol dipropionate, ethinyl estradiol (microfollin), estradiol (estraderm-TTS, Klimara), estriol, conjugated estrogens
Oral contraceptives	Non-ovlon, anteovin, triquilar
Antiandrogens	Danazol, cyproterone acetate (Diane-35)
Antiestrogens	Clostilbegit (clomiphene citrate), tamoxifen
Gonadotropins	Pergonal (FSH+LH), metrodin (FSH), profazi (LH) choriogonin
Gonadotropin-releasing hormone agonists	Zoladex, buserelin, decapeptyl, decapeptyl depot
Dopamine agonists	Parlodel, Norprolact, Dostinex
Analogues of hormones and other endocrine glands	Thyroid and antithyroid drugs, corticosteroids, anabolics, insulins

In patients with infertility of endocrine genesis, additional use of ovulation stimulants is indicated.

As a first stage of treatment for patients with infertility, it is possible to prescribe combined OCs (non-ovlon, triquilar, etc.) in order to achieve a rebound effect (withdrawal syndrome). OCs are used according to the usual contraceptive scheme for 2-3 months. If there is no effect, one should switch to direct ovulation stimulators.

• Antiestrogens - the mechanism of action of AE is based on the temporary blockade of LH-RH receptors of gonadotrophs, the accumulation of LH and FSH in the pituitary gland with the subsequent release of their increased amount into the blood with stimulation of the growth of the dominant follicle.

If there is no effect from treatment with clostilbegyt, stimulation of ovulation with gonadotropins is possible.

• Gonadotropins have a direct stimulating effect on the growth of follicles, their production of estrogens and the maturation of the egg.

Menstrual cycle disorders are not treated with gonadotropins in the following cases:

• hypersensitivity to the drug;
• ovarian cysts;
• uterine fibroids and developmental abnormalities of the genital organs incompatible with pregnancy;
• dysfunctional bleeding;
• oncological diseases;
• pituitary tumors;
• hyperprolactinemia.
• GnRH analogues - zoladex, buserelin, etc. - are used to imitate the natural pulsed secretion of LH-RH in the body.

It should be remembered that when an artificially induced pregnancy occurs, against the background of the use of ovulation stimulants, it is necessary to prescribe preservative hormonal therapy at its early, preplacental stage (progesterone, uterozhestan, duphaston, turinal).