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  • 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–ovarian (HPO) axis.

  • image For hypoestrogenic conditions associated with primary and secondary amenorrhea, if correction of the underlying cause does not restore menses, estrogen (with a progestin) is recommended.

  • image Heavy menstrual bleeding (HMB) is generally caused by either uterine structural abnormalities or nonstructural causes.

  • 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 systems (IUS) or devices 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 IUS use.

  • image Abnormal uterine bleeding associated with ovulatory dysfunction (AUB-O) is caused by oligo- or anovulation, leading to irregular, heavy menstrual bleeding due to chronic unopposed estrogen on the endometrium.

  • image Polycystic ovary syndrome (PCOS) can present as AUB-O, and symptoms include amenorrhea, oligomenorrhea, intermenstrual bleeding, and HMB. Although its exact definition continues to evolve, it is a disorder of androgen excess accompanied by ovulatory dysfunction and/or polycystic ovarian morphology. Insulin resistance is often present, and PCOS is a risk factor for the metabolic syndrome, type 2 diabetes, dyslipidemia, hypertension, and possibly cardiovascular disease.

  • image Combined hormonal contraceptives (CHCs) alone should be recommended for the management of irregular menstrual cycles and clinical hyperandrogenism in adult women and adolescents with PCOS.

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


Preclass Engaged Learning Activity

Watch the video entitled “The Menstrual Cycle” This 9-minute video provides an overview of a normal menstrual cycle and its hormonal regulation. The video is useful to enhance student understanding of the pathophysiology of various menstrual disorders.


Patient Care Process for Menstruation-Related Disorders



  • Patient characteristics (age)

  • Patient medical history

    • First day of the last menstrual cycle

    • Age of menarche

    • Cycle length and predictability

    • Number of days of each menstrual cycle, and the number of absorbent products used per day

    • History of current symptoms including relationship with menstrual cycles

    • Menstrual diary and recorded symptoms

  • Social history (eg, tobacco/ethanol use), dietary and physical activity habits (especially for women with PCOS)

  • Current medications including over-the-counter nonsteroidal anti-inflammatory drug (NSAID) use, herbal products, and dietary supplements

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, weight

    • Labs depend on suspected underlying conditions. Common labs include follicle stimulating hormone (FSH) and thyroid stimulating hormone ...

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