Skip to Main Content


For the chapter in the Wells Handbook, please go to Chapter 80. Erectile Dysfunction.



  • image While a urine pregnancy test should be one of the first steps in evaluating amenorrhea, the majority of primary amenorrhea case can be attributed to either physical anomalies of the gonads, outflow tract or anomalies of the hypothalamic–pituitary axis.

  • image For hypoestrogenic conditions associated with primary and secondary amenorrhea, estrogen (with a progestin) is provided.

  • image Heavy menstrual bleeding (HMB) is generally caused by either systemic disorders or specific uterine abnormalities.

  • image Pregnancy, including intrauterine pregnancy, ectopic pregnancy, and miscarriage, must be at the top of the differential diagnosis for any woman presenting with heavy menses.

  • image When compared to other conventional medical therapies used for HMB, the levonorgestrel intrauterine system is associated with a 61% lower discontinuation rate and 82% fewer treatment failures.

  • image Intrauterine devices (IUDs) are considered therapeutic options in a variety of menstruation-related disorders. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) indicate that both nulliparous and multiparous women at low risk of sexually transmitted diseases are good candidates for IUD use.

  • image Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) is a spectrum of disorders commonly associated with heavy or irregular bleeding from the endometrium which primarily results from a dysfunctioning menstrual system, specifically the effects of chronic unopposed estrogen.

  • image Polycystic ovary syndrome (PCOS) can present as a variety of menstruation disorders, including amenorrhea, HMB, and anovulatory bleeding. Although its definition continues to evolve, it is generally considered a disorder of androgen excess that often includes polycystic ovarian morphology and ovulatory dysfunction.

  • image Metformin use for anovulatory bleeding associated with PCOS is beneficial not only for managing AUB-O and positively affecting fertility but also for improving glucose tolerance and other metabolic parameters that contribute to cardiovascular risk.

  • image The selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacologic treatment options for premenstrual dysphoric disorder (PMDD).

Problems related to the menstrual cycle are exceedingly common in women of reproductive age. This chapter discusses the most frequently encountered menstruation-related difficulties: amenorrhea; heavy menstrual bleeding (HMB); abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O), including polycystic ovary syndrome (PCOS); dysmenorrhea; and premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). The need for effective treatments of these disorders stems from their negative impact on any or all of the following: quality of life, reproductive health, and long-term detrimental health effects, such as increased risk of osteoporosis with amenorrhea and cardiovascular disease with PCOS.


Amenorrhea is described as either primary or secondary in nature. Primary amenorrhea is the absence of menses by age 16 years in the presence of normal secondary sexual development or the absence of menses by age 14 in the absence of normal secondary sexual development.1 Secondary amenorrhea is the absence of menses for three cycles or for 6 months ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.