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  • imageA urine pregnancy test should be one of the first steps in evaluating amenorrhea; however, the majority of primary amenorrhea cases can be attributed to either physical anomalies of the gonads, outflow tract, or anomalies of the hypothalamic–pituitary–ovarian (HPO) axis.

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

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

  • imagePregnancy, including intrauterine pregnancy, ectopic pregnancy, and miscarriage, is at the top of the differential diagnosis for any person presenting with heavy menses.

  • imageThe levonorgestrel intrauterine system (IUS) is associated with a 61% lower discontinuation rate and 82% fewer treatment failures when compared to other conventional pharmacotherapies for HMB.

  • imageIntrauterine devices (IUD) or IUS are considered therapeutic options in a variety of menstruation-related disorders. The American College of Obstetricians and Gynecologists (ACOG) guidelines indicate that both nulliparous and multiparous females at low risk of sexually transmitted diseases are good candidates for IUS use.

  • imageAbnormal 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.

  • imagePolycystic ovary syndrome (PCOS) can present as AUB-O, and symptoms include amenorrhea, oligomenorrhea, intermenstrual bleeding, and HMB. Its exact definition continues to evolve, but 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.

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

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



Watch this video about the Menstrual Cycle.

Alternatively, watch the video entitled "The Menstrual Cycle." This 9-minute video provides an overview of a normal menstrual cycle and its hormonal regulation and is useful to enhance understanding of the pathophysiology of various menstrual disorders.

Guided questions for videos:

  1. Describe the major role of the following hormones in regulation of the normal menstrual cycle:

    1. GnRH

    2. LH

    3. FSH

    4. Estrogen

    5. Progesterone

  2. What hormone levels are highest and lowest in the follicular phase of the normal menstrual cycle and what outcome occurs as a result?

  3. What hormone levels are highest and lowest in the luteal phase of the normal menstrual cycle and what outcome occurs as a result?

  4. Describe folliculogenesis. What does this term mean, in what phase of the menstrual cycle does this occur, and what hormones are most active during this process?

  5. Describe the corpus luteum. What is it, in what phase of the menstrual cycle does it develop, and what hormones are most active while it is present?

  6. Draw the ...

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