Menstrual disorders are disruptive physical and/or emotional symptoms just before and during menstruation including excessive and prolonged menstruation, variations in length of the menstrual cycle, missed periods, mood swings.

Pathophysiology of the menstrual cycle

Menstruation is the result of a complex hormonal pathway regulated by the hypothalamic-pituitary-gonadal reproductive axis. The first signal starts from the hypothalamus of the brain, which secretes GnRH in pulses. In response, the anterior part of the pituitary gland secretes gonadotropins (FSH and LH) into the blood circulation. Gonadotropins stimulate the ovarian production of a variety of steroid hormones (estradiol, progesterone, androstenedione, testosterone, inhibin, activin and insulin-like growth factor-I).

At the beginning of the menstrual cycle, the follicle-stimulating hormone (FSH) stimulates the ovaries and enhance the follicular growth. The follicles are fluid-filled cavities in the ovaries. Each follicle contains an oocyte (egg) in preliminary stage. In each cycle a single follicle will develop (dominant follicle) containing a mature egg.

During the follicular growth the estrogen levels are starting to raise. The estrogen levels are lower on the first days of the period and will reach the highest level after the selection of the dominant follicle. In the meantime, the exposed endometrium ( uterine cavity inner layer) to high estrogen levels begins thickening in preparation for a possible pregnancy. The dominant follicle, under the influence of luteinizing hormone (LH), releases the mature egg (ovulation) and in its place remains the corpus luteum, which produces progesterone. The abrupt fall of progesterone levels, in the setting of non-pregnancy, leads to hormonal imbalance inside the uterus, ending up to menstrual bleeding (period) due to endometrial apoptosis.

Characteristics of a normal menstrual cycle

A normal menstrual cycle lasts approximately 28 days but can range between 23 and 35 days. Counting from the first day of a woman’s period, the menstrual cycle is completed with the beginning of the next period.

Ovulation occurs on the 14th day for a 28-day cycle or 14 days before the start of the next period depending on the duration (for example, in a 35-day cycle ovulation it may occur on the 21st day). However, a very small percentage of women are accurate in their cycle. The normal duration of the period is 3-7 days.

The first phase of the menstrual cycle (1st day of the period until ovulation) is the follicular phase, while the second phase of the menstrual cycle (after ovulation and until the beginning of the next period) is the luteal phase. Most menstrual disorders occur in the follicular phase.

Causes of menstrual disorders

• POLYCYSTIC OVARY SYNDROME
  Polycystic Ovary Syndrome is one of the most common hormonal disorders. The main symptom is menstrual disorders, such as irregular frequency due to anovulation and interrupted blood flow due to abnormal progesterone levels.

• ENDOMETRIOSIS
  Endometriosis is the presence of endometrial tissue outside the uterus. Endometrial tissue may extend to the ovaries or the fallopian tubes, the intestine or other organs in the lower digestive tract, as well as in the area between the rectum and the uterus. Endometriosis can cause abnormal bleeding, cramps or pain before and during menstruation and discomfort.

• PREGNANCY
  Pregnancy in most cases is associated with the absence of menstruation due to hormones produced in the female body that act as inhibitors for the normal functioning of the reproductive axis.

• BODY WEIGHT
  Excessive weight gain leads to the accumulation of fat in the thigh area. The accumulated fat cells reduce the metabolism of estrogen, resulting in menstrual disorders due to hyperestrogenemia. Respectively, abrupt weight loss and a low BMI <18.5 lead to hormonal disorder by inhibiting estrogen production and ovulation.

• AGE
  Age plays a very important role in menstrual disorders. The stabilization of the menstrual cycle after menarche, that is, the first appearance of menstruation in adolescence, may take months or even years. Respectively, in pre-menopause, that is, the period before menopause, menstruation becomes less frequent until its complete cessation.

• STRESS
  Periods of intense stress are very likely to adversely affect a woman’s cycle. However, all the factors that can lead to such symptoms need to be excluded.  

• ALCOHOL ABUSE
  Drinking too much alcohol on a daily basis can cause problems to the liver, which regulates the metabolism of hormones that play a key role in the menstrual cycle, such as estrogen and progesterone.

• CONTRACEPTIVES
  Contraceptives (pills, transdermal patches, Mirena IUD) may lead to decreased blood flow and scanty periods.

• SPORTS ACTIVITY
  Excessive exercise is often associated with lack of ovulation due to the increased production of cortisol, testosterone and prolactin. This mainly occurs to women who participate in championships.

• COEXISTING PATHOLOGY OF THE REPRODUCTIVE SYSTEM
  Reproductive system-related diseases, such as endometrial hyperplasia, uterine fibroids, endometriosis, polyps and premature ovarian failure lead to menstrual irregularities and affect the length of the period and the severity of blood flow.

• OTHER SYSTEMIC DISEASES
  Diseases of the thyroid gland, coagulopathies and irregularities in prolactin production (prolactinoma) are also causes of menstrual disorders.

Types of menstrual disorders

• Menorrhagia: This is an increased blood loss only during menstruation and is associated with the presence of fibroids, endometrial polyps, endometrial hyperplasia, thyroid disease, coagulopathies (such as Von Willebrand disease) and idiopathic (including the major category of dysfunctional bleeding).
• Uterine bleeding: It means an irregular period throughout the cycle. The main causes are: pregnancy, cervical polyps, stress, cervical cancer, polycystic ovaries and hormonal disorders (such as progesterone deficiency in the second half of the cycle).
• Amenorrhea: This is the absence of menstruation. It is distinguished into primary, when it has not appeared at all until the age of 16, and secondary, when it is interrupted for more than 90 days in a woman with a previously normal period (polycystic ovary syndrome, stress, environmental changes, thyroid disease and hyperprolactinaemia, excluding the cases of pregnancy, breastfeeding and menopause).
• Oligomenorrhea: This is a cycle of more than 40 days that often can lead to secondary amenorrhea with interruption of the period for 6 months. It refers to unstable and sparse menstruation (Polycystic ovary syndrome, excessive exercise, stress, weight loss)
• Sparse menstruation: It refers to duration of the menstrual cycle for more than 35 days.
• Frequent menstruation: It refers to duration of the menstrual cycle for less than 21 days.
• Polymenorrhea: This is a prolonged period of menstruation with increased blood loss (fibroids / coagulopathies / thyroid disease)
• Dysmenorrhea: Characterized by severe menstrual pain, cramps, dizziness, migraine and sickness (idiopathic / endometriosis)

Diagnosis & treatment of menstrual disorders

Any disorder observed in the menstrual cycle should be investigated by a specialized gynecologist. Obtaining a detailed gynecological, including medical and operational history, as well as life style habits (daily exercise, exposure to prolonged stress and diet) is the first step before establish the appropriate investigations and exploring the available treatment options.

The initial assessment includes a Pap test, hormonal blood tests, an ultrasound exam or even an endometrial biopsy.

Depending on the results, hormonal enhancement, discontinuation of medications that affect menstruation or even surgery such as polyp removal, hysteroscopy, laparoscopy or even hysterectomy (in rare cases of postmenopausal bleeding) may be deemed necessary.

The treatment chosen for menstrual disorders always depends on the cause. Therefore, any symptoms should always be evaluated by a gynecologist for early diagnosis and treatment.