Menstrual disorders occur when certain factors interrupt a woman’s menstrual cycle. In normal function, the menstrual cycle lasts from 21 to 42 days. It includes the growth of the uterine lining, (endometrium) and its shedding during menstruation. Hormones in the brain and the ovaries control the menstrual cycle in women in their reproductive years.

Many disruptions and disorders can affect the menstrual cycle. Pregnancy is one of the most common. When a woman becomes pregnant, her menstrual cycle is disrupted because the uterine lining remains to provide a place for the fertilized egg to implant and grow. Menstrual disorders can also affect menstruation. These disorders can be temporary or permanent and may have an effect on the patient’s fertility.

Common menstrual disorders include missed periods (amenorrhea), as well as periods that are unusually heavy or long (menorrhagia), unusually light (hypomenorrhea), unusually frequent (polymenorrhea), unusually infrequent (oligomenorrhea) and unusually painful (dysmenorrhea).

Menstrual disorders can be caused by a wide variety of conditions and diseases. Common causes include failure of the ovary to release an egg (anovulation), polycystic ovarian syndrome (PCOS), endometriosis, pelvic inflammatory disease (PID), pregnancy complications, cancer, and uterine disorders such as polyps or fibroids. Pregnancy is the most common cause of a missed period.

Physicians may use laboratory tests and imaging tests, review the patient’s medical history and perform a physical examination to help determine the underlying cause of a menstrual disorder. After the cause is determined, the physician can choose the best course of treatment, if necessary. Treatment for menstrual disorders may include lifestyle changes (e.g., dietary habits, exercise) or medications. If these options fail to alleviate the problem, surgery (e.g., dilation and curettage, endometrial ablation or resection) may be recommended in some cases.

Some of these underlying causes can have long-term health consequences for the patient. As a result, it is important for women to report all menstrual disorders to their gynecologist (GYN). In addition, young women who have not had their first period by the age of 16 years are urged to contact a GYN. Young women who have not achieved a regular period after three years of menstruating should also consult a physician. Postmenopausal women who are experiencing vaginal bleeding of any form should consult their physician as well.

Although many of the underlying causes of menstrual disorders cannot be prevented, women can reduce the risk of some disorders by maintaining a healthy lifestyle, including eating a balanced diet and getting regular exercise.

Menstrual disorders are problems related to a woman’s menstrual cycle. They are among the most common conditions in women. Many menstrual disorders are not a cause for concern, but others require a physician consultation.

Menstruation is the discharge of blood and tissue that occurs each month as part of a woman’s menstrual cycle. The cycle can vary from 21 to 42 days in length, although the average length is 28 days. This cycle is controlled by hormones produced in certain parts of the brain and the ovaries to prepare the reproductive organs for pregnancy. The lining of the uterus (endometrium) thickens in response to the hormones. If pregnancy does not occur, the lining begins to break down and discharges from the body through the vagina as the menstrual period.

Menstruation begins on average when a girl is about 12 or 13 years old (puberty) and continues monthly until menopause occurs many years later. These are considered a woman’s reproductive years and indicate the woman is physically able to become pregnant. Menstrual periods usually occur once a month and last for several days during each month. A missed menstrual period is frequently the first sign that pregnancy has occurred. The uterine lining is not shed, but rather will grow during pregnancy and provide an area for growth of the placenta (a temporary organ that provides nourishment for the developing fetus). 

As a woman ages and hormone levels slowly begin to decrease, the menstrual cycle eventually ends (menopause). Menopause typically occurs during a woman’s early 50s but it may occur earlier or later in life.

Menstrual disorders occur when certain factors interrupt the hormones that control menstruation. Common disorders include:

• Missed periods
• Periods that are unusually heavy or light
• Periods that are unusually long
• Unusually infrequent periods
• Unusually painful periods

These disorders can be temporary or permanent. In addition, many women experience some variation in menstrual cycle symptoms from one month to the next, especially during the first years after the beginning of menstruation (menarche). Some disorders may interfere with a woman’s ability to participate in everyday activities, attend work or school and sleep. Certain menstrual disorders may also interfere with a woman’s ability to become pregnant.

Women can experience a variety of menstrual disorders, including:

• Amenorrhea. An absence of menstrual periods. This condition may be further classified as:
  
  
• Primary amenorrhea. The lack of a first menstrual period by the age of 16 years. This condition is also known as “delayed menarche.”
  
  
• Secondary amenorrhea. The absence of menstrual periods in a woman who has previously menstruated regularly. The periods must be absent for at least three months to be considered amenorrhea.
  
  
• Dysmenorrhea. Severely painful menstrual periods. This condition may be further classified as:
  
  
• Primary dysmenorrhea. Painful menstrual periods that are not caused by an underlying disease or condition.
  
  
• Secondary dysmenorrhea. Painful menstrual periods caused by an underlying disease or condition. In some patients, the pain may extend beyond the menstrual period and become chronic (e.g., endometriosis).
  
  
• Hypomenorrhea. Unusually light menstrual periods.
  
  
• Menorrhagia. Unusually heavy or long menstrual periods. Women with menorrhagia may soak through one or more sanitary pads or tampons an hour for several consecutive hours, or have periods that last longer than seven days (or longer than a usual menstrual period). Menorrhagia may be a cause for concern because heavy bleeding can lead to an iron deficiency, and ultimately result in anemia.
  
  
• Metrorrhagia. Menstrual bleeding that occurs at frequent, irregular intervals.
  
  
• Menometrorrhagia. Prolonged menstrual periods that occur at irregular intervals. This condition is a combination of menorrhagia and metrorrhagia.
  
  
• Oligomenorrhea. Unusually infrequent menstrual periods. Woman with oligomenorrhea have fewer than six to eight periods per year.
  
  
• Polymenorrhea. Unusually frequent menstrual periods compared to the normal variation of menstrual cycles.
  
  
• Postmenopausal bleeding. Vaginal bleeding that occurs more than 12 months after the last menstrual cycle.
  
  
• Premenstrual syndrome (PMS).  Physical, emotional and behavioral symptoms that commonly occur in the two weeks prior to menstruation. Some women experience symptoms so severe that they interfere with daily activities. These women may have a severe condition known as premenstrual dysphoric disorder (PMDD), which is diagnosed according to specific criteria established by medical authorities.

Menstruation involves numerous structures and organs, including the hypothalamus, pituitary gland, ovaries, uterus, cervix and vagina. Menstrual disorders may occur when certain diseases or conditions interrupt the normal function of these structures.

Common causes of menstrual disorders include:

• Polycystic ovarian syndrome (PCOS). A reproductive disorder in which excessive amounts of androgens (male hormones) are produced by the ovaries. PCOS may cause a number or menstrual disorders including amenorrhea, oligomenorrhea (unusually infrequent periods) and polymenorrhea. For many women with PCOS, the menstrual disorders are caused by anovulation, or failure to ovulate, leading to fertility issues as well.
  
  
• Pregnancy and pregnancy complications. Pregnancy is the most common cause of primary amenorrhea. In addition, menorrhagia (very heavy periods) may result from miscarriage (spontaneuous loss of pregnancy before 20 weeks of gestation) or ectopic pregnancy (a pregnancy implanted outside the uterus).
  
  
• Certain forms of contraception. Starting or stopping the use of birth control pills can result in amenorrhea. Some types of oral contraceptives cause a very light or nonexistent menstrual flow. Others are designed to restrict menstruation to a specific number of cycles per year. Intrauterine devices (IUDs) can cause menorrhagia in some women, or hypomenorrhea (unusually light menstrual periods) and even amenorrhea in women using a progesterone-releasing IUD.
  
  
• Uterine disorders. Uterine fibroids (noncancerous tumors or growths within the lining of the uterus) can cause secondary dysmenorrhea, menorrhagia or metrorrhagia. Uterine polyps can cause metrorrhagia, menorrhagia or postmenopausal bleeding. Hyperplasia (thickening of the uterine lining) is a common cause of postmenopausal bleeding. Adenomyosis (condition in which glands from the endometrium become implanted in the uterine muscle) may cause unusually heavy periods.
  
  
• Endometriosis. A disorder in which the tissue that lines the uterus becomes implanted outside the uterus. The condition can lead to secondary dysmenorrhea or menorrhagia.
  
  
• Pelvic inflammatory disease (PID). An infection of the reproductive organs. PID may lead to secondary dysmenorrhea or menorrhagia.
  
  
• Thyroid disorders. Having an overactive thyroid gland (hyperthyroidism) can cause amenorrhea, and having a slow thryroid (hypothyroidism) can lead to menorrhagia.
  
  
• Gynecologic cancers and cancer treatment. Cancer of the uterus, ovaries or cervix can cause metrorrhagia (infrequent periods) or menorrhagia (heavy periods). Postmenopausal bleeding is often the result of cervical, vaginal or endometrial cancer. In addition, chemotherapy treatments can cause a woman to develop menorrhagia. Certain types of chemotherapy can also put a woman into a medical menopause and cause amenorrhea.

Additional causes include:

• Birth defects. Primary amenorrhea can result from abnormalities of the vagina or lack of reproductive organs. These congenital disorders may go undiagnosed until puberty.
  
  
• Breastfeeding. Among the most frequent causes of secondary amenorrhea is breastfeeding.
  
  
• Low body weight and excessive exercise. A low body weight can interfere with pubertal development and prevent menstruation. Women who exercise intensely (e.g., ballet dancers, gymnasts, long-distance runners) may lower the body weight enough to prevent menstruation. Women with eating disorders (e.g., anorexia nervosa) can also affect the body’s ability to function normally, preventing menstruation.
  
  
• Stress. Strong emotions such as stress can impact the body and prevent or delay menstruation.
  
  
• Hormone-secreting tumors. Certain tumors secrete hormones that interfere with the menstrual cycle, causing either absent or infrequent periods.
  
  
• Chronic illness (e.g., diabetes, lupus, liver disease, kidney disease). Certain diseases can affect the menstrual cycle causing heavy, infrequent or absent menstrual periods.
  
  
• Sexually transmitted diseases (STDs). Infection with certain STDs (e.g., gonorrhea) can cause irregular but frequent bleeding.
  
  
• Medications. The use of certain medications (e.g., anticoagulants, anti-inflammatory medications) may cause hormonal imbalances, resulting in heavy bleeding.
  
  
• Postmenopausal bleeding. Vaginal bleeding in postmenopausal women may result from atrophic vaginitis (thinning of the vaginal lining).
  
  
• Premenstrual syndrome (PMS). The exact cause of PMS is not known. However, possible causes include hormonal changes, chemical changes and diet.
  
  
• Bleeding disorders. Certain disorders of the coagulation (blood clotting) system, such as Von Willebrand’s  disease, can present with excessive menstrual bleeding.

In addition, hypomenorrhea (extremely light menstrual periods) can be a normal finding in some women. It can result from certain medications, most notably oral contraceptive pills are known to significantly reduce menstrual flow in certain women. Hypomenorrhea can also result after a woman has had certain surgical procedures aimed at reducing heavy menstrual bleeding, such as an endometrial ablation.

Menometrorrhagia and polymenorrhea are usually the result of either a structural or hormonal abnormality. Structural abnormalities that can cause frequent and/or heavy menstrual bleeding include uterine fibroids, polyps or tumors. Irregular growth of the endometrium caused by hormonal irregularities is the most common cause of heavy menstrual bleeding. Complications of pregnancy, including miscarriage, can also cause heavy bleeding.

A wide variety of underlying conditions can contribute to menstrual disorders. To pinpoint the cause, physicians rely on the patient’s medical history, physical examination and lab and imaging tests. Determining the exact cause of the menstrual disorder is important because it helps the physician plan appropriate treatment.

Physicians begin by obtaining the patient’s medical history as well as menstrual history. The details of a woman’s medical history may help the physician determine the cause of the patient’s menstrual problems. As a result, women are encouraged to be as open and honest as possible when answering the physician’s questions.

The patient may be asked about her sexual development during puberty, as well as current symptoms, medications, sexual activity and contraceptive use. The physician will also determine if the patient has a history of gynecologic disorders, gynecologic surgery, sexually transmitted diseases (STDs) or blood clotting disorders. The patient’s personal history and family history of medical conditions will be noted as well. Patients should also be prepared to answer questions regarding the growth, puberty and menstrual patterns of their female family members.

During the initial office visit, the patient should provide her physician with detailed information regarding any significant physical and emotional changes. This includes changes in weight, eating habits, exercise routine and stress level.

The physician will ask questions about the patient’s menstrual flow and menstrual cycle length. As a result, patients may benefit from recording a “menstrual diary.” This diary should include details such as the dates, type of flow and length of menstrual periods. Patients who do not have this information at the initial office visit may be asked to create and maintain one after the visit. Physicians may also ask patients to monitor their temperature each day to determine when the patient is ovulating (releasing an egg from the ovaries).

The second step in diagnosing a menstrual disorder is the physical examination. A careful evaluation of the patient will include a pelvic examination, which can reveal structural abnormalities that may be contributing to the menstrual problem.

A number of tests may be ordered following the physical exam. The tests are used to detect abnormalities and narrow the field of possible causes by eliminating certain conditions. The exact tests used vary based on the patient’s medical history, symptoms and physical findings. The tests may be performed during the initial visit or during a follow-up visit. Tests commonly used to diagnose underlying causes of menstrual disorders include:

• Urine tests. Uses a sample of urine to detect a variety of illnesses. A urine test may be performed to determine if a patient is pregnant, has a urinary tract infection, sexually transmitted diseases, or is in the process of menopause.
  
  
• Blood tests. Tests used to detect abnormally high or low levels of substances in the blood. Blood tests may be used to measure the patient’s blood count and hormone levels.
  
  
• Pap smear. Involves the collection of a sample of cells from the cervix and upper vagina. The cells are then examined for abnormalities under a microscope. This test may be used to detect infection, inflammation, cervical cancer or abnormal changes.
  
  
• Pelvic ultrasound. High-frequency sound waves are used to produce images of internal organs. This test can reveal abnormalities in the uterus, ovaries, cervix or vagina including thickening of the endometrium.
  
  
• Magnetic resonance imaging (MRI). Uses a powerful magnetic field to create images of structures and organs within the body, allowing a computer to produce clear cross-sectional or three-dimensional images. It may be ordered to determine if hypothalamic or pituitary gland abnormalities exist, as well as the presence of certain types of growths in the reproductive organs.
  
  
• Computed axial tomography (CAT scan). Allows for multiple x-rays to be taken from different angles around the patient. The “slices” or cross-sectional images of the patient’s body are analyzed by a computer. CAT scans can reveal growths or other abnormalities in areas such as the uterus or fallopian tubes.
  
  
• Endometrial biopsy. Involves the collection of a tissue sample from the endometrium (lining of the uterus). The sample is then examined for cancer or other abnormalities under a microscope.
  
  
• Hysteroscopy. A thin, lighted, flexible tube (hysteroscope) is inserted through the vagina. It allows the physician to visually examine the cervix and uterus.
  
  
• Sonohysterogram. Involves the injection of fluid through the vagina and cervix and into the uterus. An ultrasound is then used to evaluate the lining of the uterus and is particularly useful in determining the thickness of the endometrium.
  
  
• Dilation and curettage (D&C). A procedure in which the opening of the cervix is dilated or stretched and tissue from the uterus is collected. The tissue is then examined for abnormalities, signs of cancers or to ensure the complete evacuation of placental tissue after a miscarriage. It can also be performed as a diagnostic procedure for certain kinds of abnormal uterine bleeding.
  
  
• Hysterosalpingography. Involves the injection of dye through the cervix and into the uterus and fallopian tubes. X-rays are then taken to help the physician evaluate the uterus and fallopian tubes.

After the underlying cause of a menstrual disorder is uncovered, the physician can determine the best form of treatment. With the proper treatment, physicians may be able to establish or restore normal menstrual periods and possibly fertility.

Treatment decisions are based on a number of factors, including:

• Cause and extent of the disorder
• Predicted progression of the disorder
• Effect of the disorder on the patient’s daily life
• The patient’s age and overall health
• The patient’s medical history
• The patient’s tolerance for certain medications, procedures and therapies
• The patient’s personal preferences
• Fertility

Common treatments include:

• Oral contraceptives. Birth control pills may be used to treat menstrual disorders. There is a wide variety of types and forms available, and these medications are commonly used to treat polycystic ovarian syndrome and endometriosis, and to regulate irregular menstrual cycles.
  
  
• Hormone replacement therapy. Hormonal medications containing estrogen, and in some cases progesterone, may be recommended for the symptoms of menopause.
  
  
• Lifestyle changes. A physician may recommend changes in diet and exercise regimen.
  
  
• Analgesics (e.g., ibuprofen). Painkillers may be used to relieve pelvic pain and discomfort associated with menstrual disorders. Additionally, ibuprofen has been shown to decrease menstrual bleeding in some studies.

In some cases medication can trigger a menstrual disorder. Physicians may recommend that patients with medication-induced menstrual disorders switch to another medication.

Lifestyle changes and medications are usually the first line of treatment for menstrual disorders. However, these methods are not always successful and surgery may be recommended.

Surgeries that may be used to treat certain menstrual disorders include:

• Dilation and curettage (D&C). During D&C, the uterus is widened (dilated). The physician then removes the tissue by suction or sharp curettage (scraping). In some cases, a long metal instrument with a loop on the end (curette) will be used to scrape the walls of the uterus after suctioning, a process known as curettage. This procedure may be used to remove abnormal growths (e.g., polyps, fibroids) or cancer.
  
  
• Endometrial ablation (EMA). During EMA, the physician uses a hysteroscope (a thin, lighted, flexible tube) to view the uterine lining. Then one of several different methods (e.g., laser, electrocautery instrument, thermal balloon) is used to remove or destroy the uterine lining. Pregnancy is not possible after EMA.
  
  
• Endometrial resection (EMR). A surgical procedure involving the removal of the endometrial lining (the lining of the uterus) with an electrosurgical wire loop. In addition to removing the uterine lining, a quarter-inch of the uterus’ underlying muscle is removed. Resection can be used in women who have heavy bleeding but do not have any other underlying uterine problems. Pregnancy is not possible after an EMR.
  
  
• Hysterectomy. In some severe circumstances the surgical removal of a woman’s uterus may be necessary.

In some cases, the diagnosis of an underlying condition such as cancer or early menopause can result in extreme distress. As a result, psychological counseling is sometimes a component of treatment.

Many of the underlying causes of menstrual disorders cannot be prevented. However, women can reduce the risk of some causes by maintaining a healthy lifestyle, including eating a balanced diet and getting regular exercise.

Beneficial steps include:

• Making appropriate changes in diet and exercise activity to achieve a healthy weight. Polycystic ovarian syndrome, for example, can often be managed by maintaining a healthy weight. Women may wish to consult a registered dietician for assistance with dietary changes. Women with eating disorders, such as anorexia nervosa, may need to gain weight in order to restore normal menstruation.
  
  
• Avoiding recreational drug use, excessive alcohol consumption and cigarette smoking.
  
  
• Striving for a healthy balance in work, recreation and rest.
  
  
• Assessing areas of stress or conflict in life. If necessary, contacting a mental health professional (e.g., psychologist, psychiatrist) for help dealing with stress.

In addition, women should take the proper steps to protect themselves from sexually transmitted diseases. This includes using condoms consistently during sexual contact, especially with high-risk partners. These include sexual partners who have multiple sexual partners, people whose sexual background is unknown and intravenous drug users.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions related to menstrual disorders:

1. Do my symptoms indicate a menstrual disorder?
   
   
2. What tests will you use to determine the cause of my menstrual disorder?
   
   
3. What type of menstrual disorder do I have?
   
   
4. What may have caused me to develop a menstrual disorder?
   
   
5. Does having this menstrual disorder pose any danger to my overall health?
   
   
6. What are my treatment options?
   
   
7. Will my menstrual disorder affect my ability to get pregnant now or in the future?
   
   
8. Will I be able to achieve a normal menstrual cycle with treatment? If so, when can I expect to see results?
   
   
9. Are my daughters more likely to develop menstrual disorders because I have one?
   
   
10. Will my menstrual problems go away after menopause?