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11/27/12

Menstrual disorders

Menstrualdisorders
Highlights
MenstrualDisorders Menstrualdisordersinclude: Painfulcramps(dysmenorrhea)duringmenstruation.Primary dysmenorrheaiscausedbymenstruationitself.Secondary dysmenorrheaistriggeredbyanothercondition,suchasendometriosis oruterinefibroids. Heavybleeding(menorrhagia)includesprolongedmenstrualperiodsor excessivebleeding. Absenceofmenstruation(amenorrhea).Primaryamenorrheais consideredwhenagirldoesnotbegintomenstruatebytheageof16. Secondaryamenorrheaoccurswhenperiodsthatwerepreviously regularstopforatleast3months. Lightorinfrequentmenstruation(oligomenorrhea)referstomenstrual periodsthatoccurmorethan35daysapart.Itusuallyisnotacausefor concern,exceptifperiodsoccurmorethan3monthsapart. TreatmentforMenstrualDisorders Treatmentoptionsformenstrualdisordersinclude: Acetaminophen(Tylenol,generic)ornonsteroidalantiinflammatory drugs(NSAIDs),suchasibuprofen(Advil,Motrin,generic)and naproxen(Aleve,generic)canhelpprovidepainreliefforcramps. Oralcontraceptives(birthcontrolpills)canhelpregulatemenstrual periodsandreduceheavybleeding.Newercontinuousdosingoral contraceptivesreduceoreliminatemenstrualperiods.TheLNGIUS (Mirena),aprogesteroneintrauterinedevice(IUD),isoften recommendedasafirstlinetreatmentforheavybleeding Endometrialablationisasurgicaloption.Insomecases,hysterectomy maybeconsidered. DrugApproval In2012,theFoodandDrugAdministration(FDA)approvedthebirthcontrolpillNataziaasatreatmentforheavy menstrualbleeding.Oralcontraceptives(OCs)areoftenprescribedtohelpwithmenstrualdisordersbutthisisthefirstOC approvedspecificallyforthispurpose.NataziaisacombinationOCthatcontainstheestrogenestradiolandthe progesteronedienogest.

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Introduction
Menstrualdisordersareproblemsthataffectawomansnormalmenstrualcycle.Theyincludepainfulcrampsduring bleeding,abnormallyheavybleeding,ornothavinganybleeding. Menstruationoccursduringtheyearsbetweenpubertyandmenopause.Menstruation,alsocalleda"period,"isthe monthlyflowofbloodfromtheuterusthroughthecervixandoutthroughthevagina. Theuterusisapearshapedorganlocatedbetweenthebladderandlowerintestine. Thecervixisthelowerportionoftheuterus.Ithasanarrowopeningcalledtheos,whichconnectstothevagina andallowsmenstrualbloodtoflowoutoftheuterusintothevagina. Thefallopiantubesconnecttheuterusandovaries.Ovariesareeggproducingorgansthathold200,000 400,000follicles(fromfolliculus,meaning"sack"inLatin).Thesecellularsackscontainthematerialsneededto produceripenedeggs,orova.Aneggdevelopswithinthefollicle. Theendometriumistheinnerliningoftheuterus.Duringpregnancyitthickensandbecomesenrichedwithblood vesselstohouseandnourishthegrowingfetus. Ifpregnancydoesnotoccur,theendometriumisshedandawomanstartsmenstruating.Menstrualflowalso consistsofbloodandmucusfromthecervixandvagina.

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Theuterusisahollowmuscularorganlocatedinthefemalepelvisbetweenthebladderandrectum.Theovariesproduce theeggsthattravelthroughthefallopiantubes.Oncetheegghaslefttheovaryitcanbefertilizedandimplantitselfinthe liningoftheuterus.Themainfunctionoftheuterusistonourishthedevelopingfetuspriortobirth. TheMenstrualCycle Themenstrualcycleisregulatedbythecomplexsurgeandfluctuationsinmanydifferentreproductivehormones,which worktogethertoprepareawomensbodyforpregnancy.Thehypothalamus(anareainthebrain)andthepituitarygland controlsiximportanthormones:

Clicktheicontoseeanimageofthehypothalamusand pituitarygland.

Gonadotropinreleasinghormone(GnRH)isreleasedbythehypothalamus. GnRHstimulatesthepituitaryglandtoproducefolliclestimulatinghormone(FSH)andluteinizinghormone(LH). Estrogen,progesterone,andthemalehormonetestosteronearesecretedbytheovariesatthecommandofFSH andLH. Themenstrualcyclebeginswiththefirstdayofbleeding.Themenstrualcycleisdividedintothreephases: Follicular.Thefollicularphasebeginswithmenstrualbleeding.Atthestartofthisphase,estrogenand progesteronelevelsareattheirlowestpoint,whichcausestheuterineliningtobreakdownandshed.Atthesame time,thehypothalamusproducesGnRHwhichstimulatesproductionofFSHandLH.AsFSHlevelsincrease,they signaltheovariestoproducefollicles.Eachfolliclecontainsanegg.AsFSHlevelssurgeanddecline,onlyone follicleanditseggcontinuestodevelop.Thematuringfolliclereleasesestrogen,whichsignalsthataneggis matureandreadyforeggrelease(ovulation). Ovular.Ovulationmarksthehalfwaypointinthemenstrualcycle.TheovularphasebeginswithasurgeinLHand FSHlevels.Ovulationoccursabout1236hoursafterLHlevelssurge.Thefollicleburstsandreleasestheegg, whichtravelsdownthefallopiantubetotheuterus.(Somewomenexperienceaquickdullabdominalpaincalled mittelschmerz[middlepainbecauseitoccursinthemiddleofthemonthlycycle]whenthefollicleruptures.)A womanismostlikelytogetpregnantinthe35daysbeforeovulationorthedayofovulation.Theeggcanlivefor upto24hoursafterbeingreleased. Luteal.Afterreleasingtheegg,therupturedfollicleclosesandformscorpusluteum,ayellowmassofcellsthat provideasourceofestrogenandprogesteroneduringpregnancy.Thesehormoneshelptheuterineliningto thickenandpreparefortheeggsfertilization.Iftheeggisfertilizedbyaspermcell,itimplantsintheuterusand pregnancybegins.Iffertilizationdoesnotoccur,theeggbreaksapart.Thecorpusluteumdegenerates,and estrogenandprogesteronelevelsdrop.Finally,thethickeneduterineliningsloughsoffandisshedalongwiththe unfertilizedeggduringmenstruationandthemenstrualcyclebeginsagain.

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Clicktheicontoseeanimageofthecorpusluteum.

TypicalMenstrualCycle

MenstrualPhases

TypicalNo.ofDays

HormonalActions

Follicular(Proliferative) CycleDays16:Beginning Phase ofmenstruationtoendof bloodflow.

Estrogenandprogesteronestartoutattheirlowestlevels. FSHlevelsrisetostimulatematurityoffollicles.Ovariesstart producingestrogenandlevelsrise,whileprogesteronelevels remainslow.

CycleDays713:The endometriumthickensto preparefortheegg implantation.

Ovulation

CycleDay14:

SurgeinLH.Largestfollicleburstsandreleasesegginto fallopiantube.

Luteal(Secretory) Phase,alsoknownas thePremenstrual Phase

CycleDays1528:

Rupturedfollicledevelopsintocorpusluteum,whichproduces progesterone.Progesteroneandestrogenstimulateblanketof bloodvesselstoprepareforeggimplantation.

Iffertilizationoccurs:

Fertilizedeggattachestoblanketofbloodvesselsthatsupplies nutrientsforthedevelopingplacenta.Corpusluteumcontinues toproduceestrogenandprogesterone.

Iffertilizationdoesnotoccur:

Corpusluteumdeteriorates.Estrogenandprogesteronelevels drop.Thebloodvesselliningsloughsoff,andmenstruation begins.

Clicktheicontoseeananimationaboutthemenstrual cycle.

FeaturesofMenstruation OnsetofMenstruation(Menarche).Theonsetofmenstruation,calledthemenarche,typicallybeginsbetweentheagesof 1213years.Menarchegenerallyoccurs23yearsafterinitialbreastdevelopment(breastbudding).AfricanAmerican andHispanicgirlstendtomatureslightlyearlierthanCaucasiangirls.Ahigherbodymassindex(BMI)duringchildhood isassociatedwithearlierpubertyandmenarche.Environmentalfactorsandnutritionmayalsoaffectwhenmenstruation begins. LengthofMonthlyCycle.Theaveragemenstrualcycleisabout28daysbutanywherefrom21daysto35daysis considerednormal.Cyclestendtobelongerduringtheteenageyearsandtheyalsolengthenwhenawomanreaches her40s.Cyclelengthismostirregulararoundthetimethatgirlsfirststartmenstruating(menarche)andwhenwomenstop DurationofPeriods.Mostwomenbleedforaround35daysbutanormalperiodcanlastanywherefrom27days.

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NormalAbsenceofMenstruation.Normalabsenceofperiodscanoccurinanywomanunderthefollowingcircumstances: Menstruationstopsduringpregnancy.Somewomencontinuetohaveirregularbleedingduringthefirsttrimester. Thisbleedingmayindicateamiscarriageandrequiresimmediateattentionbythedoctor. Whenwomenbreastfeedtheyareunlikelytoovulate.Afterthattime,menstruationusuallyresumes,andtheyare fertileagain. Perimenopausestartswhentheintervalsbetweenperiodsbegintolengthen,anditendswithmenopauseitself (thecompletecessationofmenstruation).Menopauseusuallyoccursataboutage51,althoughsmokersoftengo throughmenopauseearlier.

MenstrualDisorders
Thereareanumberofdifferentmenstrualdisorders.Problemscanrangefromheavy,painfulperiodstonoperiodsatall. Therearemanyvariationsinmenstrualpatterns,butingeneralwomenshouldbeconcernedwhenperiodscomefewer than21daysormorethan3monthsapart,oriftheylastmorethan10days.Sucheventsmayindicateovulationproblems orothermedicalconditions. Dysmenorrhea(PainfulCramps) Dysmenorrheaissevere,frequentcrampingduringmenstruation.Painoccursinthelowerabdomenbutcanspreadto thelowerbackandthighs.Dysmenorrheaisusuallyreferredtoasprimaryorsecondary. Primarydysmenorrhea.Primarydysmenorrheaiscrampingpaincausedbymenstruation.Thecrampsoccurfrom contractionsintheuterusandareusuallymoresevereduringheavybleeding. Secondarydysmenorrhea.Secondarydysmenorrheaismenstrualrelatedpainthataccompaniesanothermedicalor physicalcondition,suchasendometriosisoruterinefibroids. Menorrhagia(HeavyBleeding) Duringanormalmenstrualcycle,theaveragewomanlosesabout1ounce(30mL)ofblood.Mostwomenchangetheir tamponsorpadsaround36timesperday.Menorrhagiaisthemedicaltermforsignificantlyheavierperiods. Menorrhagiacanbecausedbyanumberoffactors. Womenoftenoverestimatetheamountofbloodlostduringtheirperiods.Clotformationisfairlycommonduringheavy bleedingandisnotacauseforconcern.However,womenshouldconsulttheirdoctorifanyofthefollowingoccurs: Soakingthroughatleastonepadortamponevery12hoursforseveralhours Heavyperiodsthatregularlylast10ormoredays Bleedingbetweenperiodsorduringpregnancy.Spottingorlightbleedingbetweenperiodsiscommoningirlsjust startingmenstruationandsometimesduringovulationinyoungadultwomen,butitisstillagoodideatospeak withadoctor.Womenwhoexperienceanypostmenopausalbleedingshoulddefinitelycontacttheirdoctors. Menorrhagiaismenstrualflowthatlastslongerandisheavierthannormal.Thebleedingoccursatregularintervals (duringperiods).Itusuallylastsmorethan7daysandwomenloseanexcessive(morethan80mL)amountofblood. Menorrhagiaisoftenaccompaniedbydysmenorrheabecausepassinglargeclotscancausepainfulcramping. Menorrhagiaisatypeofabnormaluterinebleeding.Othertypesofabnormalbleedingare: Metrorrhagia,alsocalledbreakthroughbleeding,referstobleedingthatoccursatirregularintervalsandwith variableamounts.Thebleedingoccursbetweenperiodsorisunrelatedtoperiods. Menometrorrhagiareferstoheavyandprolongedbleedingthatoccursatirregularintervals.Menemetrorrhagia combinesfeaturesofmenorrhagiaandmetrorrhagia.Thebleedingcanoccuratthetimeofmenstruation(like menorrhagia)orinbetweenperiods(likemetrorrhagia). Dysfunctionaluterinebleeding(DUB)isageneraltermforabnormaluterinebleedingthatusuallyreferstoextraor excessivebleedingcausedbyhormonalproblems,usuallylackofovulation(anovulation).DUBtendstooccurs eitherwhengirlsbegintomenstruateorwhenwomenapproachmenopause,butitcanoccuratanytimeduringa woman'sreproductivelife. Othertypesofabnormaluterinebleedingincludebleedingaftersexandbleedingaftermenopause. Amenorrhea(AbsenceofMenstruation) Amenorrheaistheabsenceofmenstruation.Therearetwocategories:primaryamenorrheaandsecondaryamenorrhea. Thesetermsrefertothetimewhenmenstruationstops: Primaryamenorrheaoccurswhenagirldoesnotbegintomenstruatebyage16.Girlswhoshownosignsof sexualdevelopment(breastdevelopmentandpubichair)byage13shouldbeevaluatedbyadoctor.Anygirlwho

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doesnothaveherperiodbyage15shouldbeevaluatedforprimaryamenorrhea. Secondaryamenorrheaoccurswhenperiodsthatwerepreviouslyregularstopforatleast3months. Oligomenorrhea(LightorInfrequentMenstruation) Oligomenorrheaisaconditioninwhichmenstrualcyclesareinfrequent,greaterthan35daysapart.Itisverycommonin earlyadolescenceanddoesnotusuallyindicateamedicalproblem. Whengirlsfirstmenstruatetheyoftendonothaveregularcyclesforseveralyears.Evenhealthycyclesinadultwomen canvarybyafewdaysfrommonthtomonth.Periodsmayoccurevery3weeksinsomewomen,andevery5weeksin others.Flowalsovariesandcanbeheavyorlight.Skippingaperiodandthenhavingaheavyflowmayoccurthisismost likelyduetomissedovulationratherthanamiscarriage. PremenstrualSyndrome(PMS) Premenstrualsyndrome(PMS)isasetofphysical,emotional,andbehavioralsymptomsthatoccurduringthelastweekof thelutealphase(aweekbeforemenstruation)inmostcycles.Thesymptomstypicallydonotstartuntilatleastday13in thecycle,andresolvewithin4daysafterbleedingbegins.Womenmaybegintohavepremenstrualsyndromesymptoms atanytimeduringtheirreproductiveyears,butitusuallyoccurswhentheyareintheirlate20stoearly40s.Once established,thesymptomstendtoremainfairlyconstantuntilmenopause,althoughtheycanvaryfromcycletocycle.

Causes
Manydifferentfactorscantriggermenstrualdisorders,suchashormoneimbalances,geneticfactors,clottingdisorders, andpelvicdiseases. CausesofDysmenorrhea(PainfulPeriods) Primarydysmenorrheaiscausedbyprostaglandins,hormonelikesubstancesthatareproducedintheuterusandcause theuterinemuscletocontract.Prostaglandinsalsoplayaroleintheheavybleedingthatcausesdysmenorrhea. Secondarydysmenorrheacanbecausedbyanumberofmedicalconditions.Commoncausesofsecondary dysmenorrheainclude: Endometriosis.Endometriosisisachronicandoftenprogressivediseasethatdevelopswhenthetissuethatlines theuterus(endometrium)growsontootherareas,suchastheovaries,bowels,orbladder.Itoftencauseschronic pelvicpain.

Endometriosisistheconditioninwhichthetissuethatnormallylinestheuterus(endometrium)growsonotherareasof thebody,causingpainandirregularbleeding. UterineFibroid.Fibroidsarenoncancerousgrowthsthatgrowonthewallsoftheuterus.Theycancauseheavy

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bleedingduringmenstruationandcrampingpain. OtherCauses.Pelvicinflammatorydisease,ovariancysts,andectopicpregnancy.Theintrauterinedevice(IUD) contraceptivecanalsocausesecondarydysmenorrhea. CausesofMenorrhagia(HeavyBleeding) Therearemanypossiblecausesforheavybleeding: HormonalImbalances.Imbalancesinestrogenandprogesteronelevelscancauseheavybleeding.Hormonal imbalancesarecommonaroundthetimeofmenarcheandmenopause. OvulationProblems.Ifovulationdoesnotoccur(anovulation),thebodystopsproducingprogesterone,whichcan causeheavybleeding. UterineFibroids.Uterinefibroidsareaverycommoncauseofheavyandprolongedbleeding. UterinePolyps.Uterinepolyps(smallbenigngrowths)andotherstructuralproblemsorotherabnormalitiesinthe uterusmaycausebleeding. EndometriosisandAdenomyosis.Endometriosis,aconditioninwhichthecellsthatlinetheuterusgrowoutsideof theuterusinotherareas,suchastheovaries,cancauseheavybleeding.Adenomyosis,arelatedconditionwhere endometrialtissuedevelopswithinthemusclelayersoftheuterus,canalsocauseheavybleedingandmenstrual pain. MedicationsandContraceptives.Certaindrugs,includinganticoagulantsandantiinflammatorymedications,can causeheavybleeding.Problemslinkedtosomebirthcontrolmethods,suchasbirthcontrolpillsorintrauterine devices(IUDs)cancausebleeding. BleedingDisorders.Bleedingdisordersthatstopbloodfromclottingcancauseheavymenstrualbleeding.Mostof thesedisordershaveageneticbasis.VonWillebranddiseaseisthemostcommonofthesebleedingdisorders. Cancer.Rarely,uterine,ovarian,andcervicalcancercancauseexcessivebleeding. Infection.Infectionoftheuterusorcervixcancausebleeding. PregnancyorMiscarriage. OtherMedicalConditions.Systemiclupuserythematosus,diabetes,pelvicinflammatorydisorder,cirrhosis,and thyroiddisorderscancauseheavybleeding.

Fibroidtumorsmaynotneedtoberemovediftheyarenotcausingpain,bleedingexcessively,orgrowingrapidly. CausesofAmenorrheaandOligomenorrhea(AbsentorLightPeriods) Normalcausesofskippedorirregularperiodsincludepregnancy,breastfeeding,hormonalcontraception,and perimenopause.Skippedperiodsarealsocommonduringadolescence,whenitmaytakeawhilebeforeovulation occursregularly.Consistentlyabsentperiodsmaybeduetothefollowingfactors: DelayedPuberty.Acommoncauseofprimaryamenorrhea(absenceofperiods)isdelayedpubertyduetosome geneticfactorthatdelaysphysicaldevelopment.Failureofovariandevelopmentisthemostcommoncauseof primaryamenorrhea. HormonalChangesandPuberty.Oligomenorrhea(lightorinfrequentmenstruation)iscommonlyexperiencedby

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girlswhoarejustbeginningtohavetheirperiods. WeightLossandEatingDisorders.Eatingdisordersareacommoncauseofamenorrheainadolescentgirls. Extremeweightlossandreducedfatstoresleadtohormonalchangesthatincludelowthyroidlevels (hypothyroidism)andelevatedstresshormonelevels(hypercortisolism).Thesechangesproduceareductionin reproductivehormones. PolycysticOvarianSyndrome(PCOS).PCOSisaconditioninwhichtheovariesproducehighamountsof androgens(malehormones),particularlytestosterone.Amenorrheaoroligomenorrheaisquitecommoninwomen whohavePCOS. Endometriosis.Endometriosis,andadenomyosis,cancauseseverepelvicpainespeciallyduringmenstruation.In endometriosis,cellsfromthetissuethatlinestheuterusgrowinsitesoutsidetheuterus.Inadenomyosis,these endometrialcellsgrowwithinandbecomeattachedtothemuscularwallsoftheuterus. ElevatedProlactinLevels(Hyperprolactinemia).Prolactinisahormoneproducedinthepituitaryglandthat stimulatesbreastdevelopmentandmilkproductioninassociationwithpregnancy.Highlevelsofprolactin (hyperprolactinemia)inwomenwhoarenotpregnantornursingcanreducegonadotropinhormonesandinhibit ovulation,thuscausingamenorrhea. PrematureOvarianFailure(POF).POFistheearlydepletionoffolliclesbeforeage40.Inmostcases,itleadsto prematuremenopause.POFisasignificantcauseofinfertility. StructuralProblems.Insomecases,structuralproblemsorscarringintheuterusmaypreventmenstrualflow. Inborngenitaltractabnormalitiesmayalsocauseprimaryamenorrhea. Stress.Physicalandemotionalstressmayblockthereleaseofluteinizinghormone,causingtemporary amenorrhea. AthleticTraining.Amenorrheaoroligomenorrheaassociatedwithvigorousactivitymayberelatedtostressand weightloss.Femaleathleteswhouseanabolicsteroidswilloftenhaveamenorrheaoroligomenorrhea.A syndromeknownasthefemaleathletetriadisassociatedwithhormonalchangesthatoccurwiththecombination ofeatingdisorders,amenorrhea,andosteopenia(lossofbonedensitythatcanleadtoosteoporosis)inyoung womenwhoexcessivelyexercise. OtherMedicalConditions.Epilepsy,thyroidproblems,celiacsprue,metabolicsyndrome,andCushing'sdisease areassociatedwithamenorrhea.

Iftheovariesproducetoomuchandrogen(hormonessuchastestosterone)awomanmaydevelopmalecharacteristics. Thisovarianimbalancecanbecausedbytumorsintheovariesoradrenalglands,orpolycysticovariandisease. Virilizationmayincludegrowthofexcessbodyandfacialhair,amenorrhea(lossofmenstrualperiod)andchangesin bodycontour.

RiskFactors
Ageplaysakeyroleinmenstrualdisorders.Girlswhostartmenstruatingatage11oryoungerareathigherriskfor severepain,longerperiods,andlongermenstrualcycles.Adolescentsmaydevelopamenorrheabeforetheirovulation cyclesbecomeregular. Womenwhoareapproachingmenopause(perimenopause)mayalsoskipperiods.Occasionalepisodesofheavy bleedingarealsocommonaswomenapproachmenopause.

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Otherriskfactorsinclude: Weight.Beingeitherexcessivelyoverweightorunderweightcanincreasetheriskfordysmenorrheaand amenorrhea. MenstrualCyclesandFlow.Longerandheaviermenstrualcyclesaredefinitelyassociatedwithpainfulcramps. PregnancyHistory.Womenwhohavehadahighernumberofpregnanciesareatincreasedriskformenorrhagia. Womenwhohavenevergivenbirthhaveahigherriskofdysmenorrhea,whilewomenwhofirstgavebirthata youngageareatlowerrisk. Smoking.Smokingcanincreasetheriskforheavierperiods. Stress.Physicalandemotionalstressmayblockthereleaseofluteinizinghormone,causingtemporary amenorrhea.

Complications
Anemia Menorrhagiaisthemostcommoncauseofanemia(reductioninredbloodcells)inpremenopausalwomen.Abloodloss ofmorethan80mL(aroundthreetablespoons)permenstrualcyclecaneventuallyleadtoanemia.Mostcasesofanemia aremild.Nevertheless,evenmildanemiacanreduceoxygentransportintheblood,causingfatigueandadiminished physicalcapacity.Moderatetosevereanemiacancauseshortnessofbreath,rapidheartrate,lightheadedness, headaches,ringingintheears(tinnitus),irritability,paleskin,restlesslegssyndrome,andmentalconfusion.Heart problemscanoccurinprolongedandsevereanemiathatisnottreated. Osteoporosis Amenorrheacausedbyreducedestrogenlevelsislinkedtoosteopenia(lossofbonedensity)andosteoporosis(more severebonelossthatincreasesfracturerisk).Conditionsthatareassociatedwithlowestrogenlevelsincludeeating disorders,pituitarytumors,andprematureovarianfailure.Becausebonegrowthisatitspeakinadolescenceandyoung adulthood,losingbonedensityatthattimeisverydangerous,andearlydiagnosisandtreatmentisessentialforlongterm health.

Osteoporosisisaconditioncharacterizedbyprogressivelossofbonedensity,thinningofbonetissue,andincreased vulnerabilitytofractures.Osteoporosismayresultfromdisease,dietaryorhormonaldeficiency,oradvancedage.Regular weightbearingexerciseandstrengthtraining,andcalciumandvitaminDsupplements,canreduceandevenreverse lossofbonedensity. Infertility Someconditionsassociatedwithheavybleeding,suchasovulationabnormalities,fibroids,orendometriosis,are importantcontributorstoinfertility.Manyconditionsthatcauseamenorrhea,suchasovulationabnormalitiesand polycysticovarysyndrome,canalsocauseinfertility.Irregularperiodsfromanycausemaymakeitmoredifficultto

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conceive.Sometimestreatingtheunderlyingconditioncanrestorefertility.Inothercases,specificfertilitytreatmentsthat useassistedreproductivetechnologiesmaybebeneficial. QualityofLife Menstrualdisorders,particularlypainandheavybleeding,canaffectschoolandworkproductivityandsocialactivities.

Diagnosis
Yourmedicalhistorycanhelpthedoctordeterminewhetheramenstrualproblemiscausedbyanothermedicalcondition. Forexample,nonmenstrualconditionsthatmaycauseabdominalpainincludeappendicitis,urinarytractinfections, ectopicpregnancy,andirritablebowelsyndrome.Endometriosisanduterinefibroidsmaycauseheavybleedingand pain.Yourdoctormayaskquestionsconcerning: Menstrualcyclepatternslengthoftimebetweenperiods,numberofdaysthatperiodslast,numberofdaysof heavyorlightbleeding Thepresenceorhistoryofanymedicalconditionsthatmightbecausingmenstrualproblems Anyfamilyhistoryofmenstrualproblems Historyofpelvicpain Regularuseofanymedications(includingvitaminsandoverthecounterdrugs) Diethistory,includingcaffeineandalcoholintake Pastorpresentcontraceptiveuse Anyrecentstressfulevents Sexualhistory MenstrualDiary.Amenstrualdiaryisahelpfulwaytokeeptrackofchangesinmenstrualcycles.Youshouldrecord whenyourperiodstarts,howlongitlasts,andtheamountofbleedingandpainthatoccursduringthecourseof menstruation. PelvicExamination.Apelvicexamisastandardpartofdiagnosis.APaptestmaybedoneduringthisexam. BloodandHormonalTests Bloodtestscanhelpruleoutotherconditionsthatcausemenstrualdisorders.Forexample,yourdoctormaytestthyroid functiontomakesurethatlowthyroid(hypothyroidism)isnotpresent.Bloodtestscanalsocheckfolliclestimulating hormone,estrogen,andprolactinlevels.Patientswhohavemenorrhagiamaygettestsforbleedingdisorders.Ifpatients arelosingalotofblood,theyshouldalsogettestedforanemia. Patientswhohaveamenorrheamayneedtoreceivespecialhormonaltests.Theprogestationalchallengetestusesoral orinjectedprogesteronetotestforafunctionaluterinelining(endometrium): Bleedingthatoccursupto3weeksaftertheprogesteronedosesuggeststhatthewomanhasnormalestrogen levelsbutisnotovulating,particularlyifthyroidandprolactinlevelsarenormal.Insuchcases,thedoctorwill checkforstress,recentweightloss,andanymedications.Suchresultscouldalsosuggestpolycysticovariesor stress. Afailuretobleedcouldindicateanabnormaluterusthatpreventsoutfloworinsufficientestrogen.Insuchcases, thenextstepmaybetoadministerestrogen,followedbyprogestin.Ifbleedingoccursafterthat,thecauseof amenorrheaisrelatedtolowestrogenlevels.Thedoctorwillthencheckforovarianfailure,anorexia,orother causesoflowestrogen.Ifbleedingdoesnotoccur,thedoctorwouldcheckforobstructionsthatarepreventing outflowofmenstruation. Ultrasound Imagingtechniquesareoftenusedtodetectcertainconditionsthatmaybecausingmenstrualdisorders.Imagingcan helpdiagnosefibroids,endometriosis,orstructuralabnormalitiesofthereproductiveorgans. UltrasoundandSonohysterography.Ultrasoundisthestandardimagingtechniqueforevaluatingtheuterusandovaries, detectingfibroids,ovariancystsandtumors,andfindingobstructionsintheurinarytract.Itusessoundwavestoproduce animageoftheorgans.Ultrasoundcarriesnoriskandcausesverylittlediscomfort. Transvaginalsonohysterographyusesultrasoundalongwithsaline(saltwater)injectedintotheuterustoenhancethe visualizationoftheuterus. OtherDiagnosticProcedures Hysteroscopy.Hysteroscopyisaprocedurethatcandetectthepresenceoffibroids,polyps,orothercausesofbleeding.It

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maymisscasesofuterinecancer,however,andisnotasubstituteformoreinvasiveprocedures,suchasdilationand curettage(D&C)orendometrialbiopsy,ifcancerissuspected. Itisdoneintheofficesettingandrequiresnoincisions.Theprocedureusesaslenderflexibleorrigidtubecalleda hysteroscope,whichisinsertedintothevaginaandthroughthecervixtoreachtheuterus.Afiberopticlightsourceanda tinycamerainthetubeallowthedoctortoviewthecavity.Theuterusisfilledwithsalineorcarbondioxidetoinflatethe cavityandprovidebetterviewing.Thiscancausecramping. Hysteroscopyisnoninvasive,butmanywomenfindtheprocedurepainful.Theuseofananestheticspraysuchas lidocainemayhelpinpreventingpainfromthisprocedure.Othercomplicationsincludeexcessivefluidabsorption, infection,anduterineperforation.Hysteroscopyisalsoperformedaspartofsurgicalprocedures. Laparoscopy.Diagnosticlaparoscopy,aninvasivesurgicalprocedure,iscurrentlytheonlydefinitivemethodfor diagnosingendometriosis,acommoncauseofdysmenorrhea.Itmayalsobeusedtotreatendometriosis.Laparoscopy normallyrequiresageneralanesthetic,althoughthepatientcangohomethesameday.Theprocedureinvolvesinflating theabdomenwithgasthroughasmallabdominalincision.Afiberoptictubeequippedwithsmallcameralenses(the laparoscope)istheninserted.Thedoctorusesthelaparoscopetoviewtheuterus,ovaries,tubes,andperitoneum(lining ofthepelvis).

Clicktheicontoseeanimageoflaparoscopy.

EndometrialBiopsy.Whenheavyorabnormalbleedingoccurs,anendometrial(uterine)biopsycanbeperformedinthe doctor'soffice.Thisprocedurecanhelpidentifyabnormalcells,whichsuggestthatcancermaybepresent.Itmayalso helpthedoctordecideonthebesthormonaltreatmenttouse.Theprocedureisdonewithoutanesthesia,orlocal anestheticisinjected. Thepatientliesonherbackwithherfeetinstirrups.Aninstrument(speculum)isinsertedintothevaginatoholdit openandallowthecervixtobeviewed. Thecervixiscleanedwithanantisepticliquidandthengraspedwithaninstrument(tenaculum)thatholdsthe uterussteady.Adevicecalledacervicaldilatormaybeneededtostretchthecervicalcanalifthereistightness (stenosis).Asmall,hollowplastictubeisthengentlypassedintotheuterinecavity. Gentlesuctionremovesasampleofthelining.Thetissuesampleandinstrumentsareremoved.Aspecialist calledapathologistexaminesthesampleunderamicroscope. DilationandCurettage(D&C).Dilationandcurettage(D&C)isamoreinvasiveprocedure: AD&Cisusuallydoneinanoutpatientsettingsothatthepatientcanreturnhomethesameday,butitsometimes requiresageneralanesthetic.Itmayneedtobeperformedintheoperatingroomtoruleoutseriousconditionsor treatsomeminoronesthatmaybecausingthebleeding. Thecervix(theneckoftheuterus)isdilated(opened). Thesurgeonscrapestheinsideliningoftheuterusandcervix. Theprocedureisusedtotakesamplesofthetissueandtorelieveheavybleedinginsomeinstances.D&Ccanalsobe effectiveinscrapingoffsmallendometrialpolyps,butitisnotusefulformostfibroids,whichtendtobelargerandmore firmlyattached.

ClicktheicontoseeanimageofaD&C.

LifestyleChanges
DietaryFactors Makingdietaryadjustmentsstartingabout14daysbeforeaperiodmayhelpsomewomenwithcertainmildmenstrual disorders,suchascramping.Thegeneralguidelinesforahealthydietapplytoeveryonetheyincludeeatingplentyof wholegrains,freshfruitsandvegetables,andavoidingsaturatedfatsandcommercialjunkfoods.

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Limitingsalt(sodium)mayhelpreducebloating.Limitingcaffeine,sugar,andalcoholintakemayalsobebeneficial. PreventingandTreatingAnemia DietaryFormsofIron.Womenwhohaveheavymenstrualbleedingcansometimesbecomeanemic.Eatingironrich foodscanhelppreventanemia.Ironfoundinfoodsiseitherintheformofhemeornonhemeiron.Hemeironisbetter absorbedthannonhemeiron. Foodscontaininghemeironarethebestsourcesforincreasingormaintaininghealthyironlevels.Suchfoods include(inorderofironrichness)clams,oysters,organmeats,beef,pork,poultry,andfish. Nonhemeironislesswellabsorbed.Asubstantialamountoftheironinmeatisnonheme(althoughmeatitself helpsabsorbnonhemeiron).Eggs,dairyproducts,andironcontainingvegetableshaveonlythenonhemeform. Suchvegetableproductsincludedriedbeansandpeas,ironfortifiedcereals,bread,andpastaproducts,dark greenleafyvegetables(chard,spinach,mustardgreens,kale),driedfruits,nuts,andseeds. IncreasingintakeofvitaminCrichfoodscanenhanceabsorptionofnonhemeiron. IronSupplements.Therearetwoformsofsupplementaliron:ferrousandferric.Ferrousironisbetterabsorbedandisthe preferredformofirontablets.Ferrousironisavailableinthreeforms:ferrousfumarate,ferroussulfate,andferrous gluconate.Dependingontheseverityofyouranemia,aswellasyourageandweight,yourdoctorwillrecommenda dosageof60200mgofelementalironperday.Thismeanstakingoneironpill23timeseachday. OtherLifestyleMeasures Exercise.Exercisemayhelpreducemenstrualpain. SexualActivity.Therehavebeenreportsthatorgasmreducestheseverityofmenstrualcramps. ApplyingHeat.Applyingaheatingpadtotheabdominalarea,orsoakinginahotbath,canhelprelievethepainof menstrualcramps. MenstrualHygiene.Changetamponsevery46hours.Avoidscentedpadsandtamponsfemininedeodorantscan irritatethegenitalarea.Douchingisnotrecommendedbecauseitcandestroythenaturalbacterianormallypresentinthe vagina.Bathingregularlyissufficient. AlternativeRemedies AcupunctureandAcupressure.Somestudieshavereportedrelieffrompelvicpainafteracupunctureoracupressure,a techniquethatappliessmallpinsorpressuretospecificpointsonthebody.Moreresearchisneeded. YogaandMeditativeTechniques.Yogaandmeditativetechniquesthatpromoterelaxationmayhelprelievemenstrual cramps. HerbsandSupplements.Generally,manufacturersofherbalremediesanddietarysupplementsdonotneedapproval fromtheFoodandDrugAdministrationtoselltheirproducts.Justlikewithdrugs,herbsandsupplementscanaffectthe body'schemistry,andthereforehavethepotentialtoproducesideeffectsthatmaybeharmful.Therehavebeena numberofreportedcasesofseriousandevenlethalsideeffectsfromherbalproducts.Patientsshouldcheckwiththeir doctorbeforeusinganyherbalremediesordietarysupplements. Studieshavenotgenerallyfoundherbalornaturalremediestobeanymoreeffectivethanplacebos(sugarpills)for reducingmenstrualdisorders.Naturalremediespromotedformenstrualsymptomsinclude: Blackcohosh(alsoknownasCimicifugaracemosaorsquawroot)containsaplantestrogenandisthemost studiedherbalremedyfortreatingmenopausalsymptoms,includingdysmenorrhea,althoughmoststudieshave indicateditisineffective.Headachesandgastrointestinalproblemsarecommonsideeffects.Itshouldnotbe takenformorethan6months. Gingerteaorcapsulesmayhelptorelievenauseaandbloating. Magnesiumsupplementsmaybehelpfulforrelievingdysmenorrhea.Somewomenalsoreportbenefitwith vitaminB1(thiamine)supplements. Aromatherapywithtopicallyappliedlavender,sage,androseoilsmayhelpeasemenstrualcramps,accordingto somesmallstudies. Pycnogenol,anextractfromthebarkoftheFrenchmaritimepinetree,mayhelpreducemenstrualpainand discomfort,accordingtosomesmallstudies.

Medications
Thereareanumberofdifferentmedicinesprescribedformenstrualdisorders.

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CommonPainRelieversforCramps NonsteroidalAntiinflammatoryDrugs(NSAIDs).Nonsteroidalantiinflammatorydrugs(NSAIDs)blockprostaglandins, thesubstancesthatincreaseuterinecontractions.Theyareeffectivepainkillersthatalsohelpcontroltheinflammatory factorsthatmayberesponsibleforheavymenstrualbleeding.AspirinisthemostcommonNSAID,buttherearedozensof othersavailableoverthecounterorbyprescription. AmongthemosteffectiveNSAIDsformenstrualdisordersareibuprofen(Advil,Motrin,MidolPMS,generic)andnaproxen (Aleve,generic),whicharebothavailableoverthecounter,andmefenamicacid(Ponstel,generic),whichrequiresa doctorsprescription.LongtermdailyuseofanyNSAIDcanincreasetheriskforgastrointestinalbleedingandulcers,so itsbesttojustusethesedrugsforafewdaysduringthemenstrualcycle.

Anulcerisacraterlikelesionontheskinormucousmembranecausedbyaninflammatory,infectious,ormalignant condition.Toavoidirritatinganulcerapersoncantryeliminatingcertainsubstancesfromtheirdietsuchascaffeine, alcohol,aspirin,andavoidsmoking.Patientscantakecertainmedicinestosuppresstheacidinthestomachcausingthe erosionofthestomachlining.Endoscopictherapycanbeusedtostopbleedingfromtheulcer. Acetaminophen.Acetaminophen(Tylenol,generic)isagoodalternativetoNSAIDs,especiallyforwomenwithstomach problemsorulcers.Someproducts(Pamprin,Premsyn,generic)combineacetaminophenwithotherdrugs,suchasa diuretic,toreducebloating.. OralContraceptives Oralcontraceptives(OCs),commonlycalledbirthcontrolpillsor"thePill,"containcombinationsofanestrogenanda progesterone(inasyntheticformcalledprogestin).TheestrogencompoundusedinmostcombinationOCsisestradiol. Therearemanydifferentprogestins,butcommontypesincludelevonorgestrol,drospirenone,norgestrol,norethindrone, anddesogestrel.(Combinationcontraceptivesarealsoavailableinotherforms,includingpatchesandvaginalrings,but theymayincreasetheriskformenstrualcrampingandbleeding.)Natazia,anOCthatcontainsestradiolandthe progesteronedienogest,isspecificallyapprovedfortreatmentofheavybleeding.

Clicktheicontoseeanimageofhormonebased contraceptives.

OCsareoftenusedtoregulateperiodsinwomenwithmenstrualdisorders,includingmenorrhagia(heavybleeding), dysmenorrhea(severepain),andamenorrhea(absenceofperiods).Oralcontraceptivesareaseffectivefortreating pelvicpainfromendometriosisasthemorepotentgonadotropinreleasinghormoneagonists.Theyalsoprotectagainst ovarianandendometrialcancers. StandardOCsusuallycomeina28pillpackwith21daysofactive(hormone)pillsand7daysofinactive(placebo) pills.Newerextendedcycle(alsocalledcontinuoususeorcontinuousdosing)oralcontraceptivesaimtoreduceor

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eveneliminatemonthlymenstrualperiods.TheseOCscontainacombinationofestradiolandtheprogestin levonorgestrel,buttheyuseextendingdosingofactivepills. Extendedcycleoralcontraceptivesinclude: SeasonaleandSeasonique,whichreduceperiodstoabout3or4timesayear Lybrel,whichcompletelyeliminatesmonthlymenstrualperiodsinmanywomen Sideeffects.CommonsideeffectsofcombinationOCsincludeheadache,nausea,bloating,breasttenderness,and bleedingbetweenperiods.TheestrogencomponentincombinationOCsisusuallyresponsibleforthesesideeffects.In general,todaysOCsaremuchsaferthanOCsofthepastbecausetheycontainmuchlowerdosagesofestrogen. However,allOCscanincreasetheriskformigraine,stroke,heartattack,andbloodclots.Theriskishighestforwomen whosmoke,whoareoverage35,orwhohaveahistoryofheartdiseaseriskfactors(suchashighbloodpressureor diabetes)orpastcardiacevents.Womenwhohavecertainmetabolicdisorders,suchaspolycysticovarysyndrome (PCOS),arealsoathigherriskfortheheartrelatedcomplicationsassociatedwiththesepills. Progestins Progestins(syntheticprogesterone)areusedbywomenwithirregularorskippedperiodstorestoreregularcycles.They alsoreduceheavybleedingandmenstrualpain,andmayprotectagainstuterineandovariancancers.Progestinonly contraceptivesmaybeagoodoptionforwomenwhoarenotcandidatesforestrogencontainingOCs,suchassmokers overtheageof35. Progestinscanbedeliveredinvariousforms. Oral.Shorttermtreatmentofanovulatorybleeding(bleedingcausedbylackofovulation)mayinvolvea21daycourseof anoralprogestinondays526.Medroxyprogesterone(Provera,generic)iscommonlyused. IntrauterineDevice(Mirena).Anintrauterinedevice(IUD)thatreleasesprogestincanbeverybeneficialformenstrual disorders,regardlessofitscontraceptiveeffects.IntheUnitedStates,alevonorgestrelreleasingintrauterinesystem,also calledanLNGIUS,issoldunderthebrandnameMirena.TheLNGIUShasbeenproventoreduceheavybleedingand paininmanywomenwhosufferfrommenorrhagiaanddysmenorrhea.ItistheonlyIUDapprovedbytheFDAtotreat heavymenstrualbleeding. ManydoctorsrecommendtheLNGIUSasafirstlinetreatmentforsevereheavymenstrualbleeding,particularlyfor womenwhomayfacehysterectomy(removalofuterus)orconservativesurgerysuchasendometrialablation(destruction oftheendometriallining).Thisdeviceisconsideredagoodlongtermoption,particularlyforwomenwhomaydesire futurepregnancies.ResearchalsoindicatesthatwomenwhochoosetheLNGIUSareassatisfiedwiththeirqualityoflife asthosewhochoosesurgery. TheLNGIUSremainsinplaceintheuterusandreleasestheprogestinlevonorgestrelforupto5years.Progestin releasedbyanIUDmainlyaffectstheuterusandcervix,andsoitcausesfewerwidespreadsideeffectsthanprogestin pillsdo.(However,theothertypeofIUDtheCopperTmayincreasebleeding.) AftertheLNGIUSisinserted,heaverperiodsmayoccurduringthefirst36monthsastheliningoftheuterusisshed. Thissheddingmayalsocauseirregularperiodsandlightbleeding(spotting)betweenmenstrualcycles.Eventually,the LNGIUSresultsinashorterperiod,withlittleornobloodflow.Formanywomen,theLNGIUScompletelystops menstrualperiods. Commonsideeffectsincludecramping,acne,backpain,breasttenderness,headache,moodchanges,andnausea.The LNGIUSmayincreasetheriskforovariancysts,butsuchcystsusuallycausenosymptomsandresolveontheirown. Womenwhohaveahistoryofpelvicinflammatorydiseaseorwhohavehadaseriouspelvicinfectionshouldnotusethe LNGIUS.Becauseoftherisksassociatedwithpelvicinfection,doctorsrecommendthatwomenwhousetheLNGIUSbe inastablemonogamousrelationship.TheLNGIUSdoesnotprotectagainstsexuallytransmitteddiseases. Injection(DepoProvera).DepoProvera(alsocalledDepoorDMPA)usestheprogestinmedroxyprogesterone,whichis administeredbyinjectiononceevery3months.MostwomenwhouseDepoProverastopmenstruatingaltogetheraftera year.DepoProveramaybebeneficialforwomenwithheavybleeding,orpainduetoendometriosis.Womenwho eventuallywanttohavechildrenshouldbeawarethatDepoProveracancausepersistentinfertilityforupto22months afterthelastinjection,althoughtheaverageis10months. Weightgaincanbeaproblem,particularlyinwomenwhoarealreadyoverweight.WomenshouldnotuseDepoProvera iftheyhaveahistoryofliverdisease,bloodclots,stroke,orcancerofthereproductiveorgans.Longterm(morethan2 years)useofDepoProveracancauselossofbonedensity.Becauseofthis,DepoProverashouldnotbeusedforlonger than2years. GnRHAgonists

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Gonadotropinreleasinghormone(GnRH)agonistsaresometimesusedtotreatseveremenorrhagia.GnRHagonists blockthereleaseofthereproductivehormonesLH(luteinizinghormone)andFSH(follicularstimulatinghormone).Asa result,theovariesstopovulatingandnolongerproduceestrogen. GnRHagonistsincludetheimplantgoserelin(Zoladex),amonthlyinjectionofleuprolide(LupronDepot),andthenasal spraynafarelin(Synarel).Suchdrugsmaybeusedaloneorinpreparationforproceduresusedtodestroytheuterine lining.Theyarenotgenerallysuitableforlongtermuse. Commonlyreportedsideeffects,whichcanbesevereinsomewomen,includemenopausallikesymptoms.These symptomsincludehotflashes,nightsweats,changesinthevagina,weightchange,anddepression.Thesideeffectsvary inintensitydependingontheGnRHagonist.Theymaybemoreintensewithleuprolideandpersistafterthedrughas beenstopped. Themostimportantconcernispossibleosteoporosisfromestrogenloss.Womenshouldnottakethesedrugsformore than6months.Addbacktherapy,whichprovidesdosesofestrogenandprogestinthatarehighenoughtomaintainbone densitybutaretoolowtooffsetthebeneficialeffectsoftheGnRHagonist,maybeused. GnRHtreatmentsusedalonedonotpreventpregnancy.Furthermore,ifawomanbecomespregnantduringtheiruse, thereissomeriskforbirthdefects.WomenwhoaretakingGnRHagonistsshouldusenonhormonalbirthcontrol methods,suchasthediaphragm,cervicalcap,orcondomswhileonthetreatments. Danazol Danazol(Danocrine,generic)isasyntheticsubstancethatresemblesamalehormone.Itsuppressesestrogen,and thereforemenstruation,andisoccasionallyused(sometimesincombinationwithanoralcontraceptive)tohelpprevent heavybleeding.Itisnotsuitableforlongtermuse,andduetoitsmasculinizingsideeffectsitisonlyusedinrarecases. GnRHagonistshavelargelyreplacedtheuseofdanazol. Adversesideeffectsincludefacialhair,deepeningofthevoice,weightgain,acne,andreducedbreastsize.Danazolmay alsoincreasetheriskforunhealthycholesterollevelsanditmaycausebirthdefects. NonHormonalDrugs(Lysteda) Tranexamicacid(Lysteda)isarecentlyapprovedmedicationfortreatingheavymenstrualbleeding.Approvedin2009,it isthefirstnonhormonaldrugformenorrhagiatreatment.Tranexamicacidisgivenasapill.Itisanantifibrinolyticdrug thathelpsbloodtoclot.TheFDAwarnsthatuseofthismedicationbywomenwhotakehormonalcontraceptivesmay increasetheriskofbloodclots,stroke,orheartattacks.Thisdrugshouldnotbetakenbywomenwhohaveahistoryof bloodclots.

Surgery
Womenwithheavymenstrualbleeding,painfulcramps,orbothhavesurgicaloptionsavailabletothem.Mostprocedures eliminateorsignificantlyaffectthepossibilityforchildbearing,however.Hysterectomyremovestheentireuteruswhile endometrialablationdestroystheuterinelining. Forsomewomen,anintrauterinedevice(IUD)thatreleasesprogestinisprovingtobeagoodmedicalalternativeto surgery.Thelevonorgestrelreleasingintrauterinesystem,orLNGIUS(Mirena),isincreasinglybeingusedinsteadof surgerytotreatheavymenstrualbleeding.StudieshavefoundtheLNGIUStoworkjustaswellasablation.Women shouldbesuretoasktheirdoctorsaboutallmedicaloptionsbeforeundergoingsurgicalprocedures. EndometrialAblation Inendometrialablation,theentireliningoftheuterus(theendometrium)isremovedordestroyed.Formostwomen,this procedurestopsthemonthlymenstrualflow.Insomewomen,menstrualflowisnotstoppedbutissignificantlyreduced. Candidates.Endometrialablationisnotappropriateforwomenwho: Havegonethroughmenopause Haverecentlybeenpregnant Wouldliketohavechildreninthefuture Havecertaingynecologicconditionssuchascanceroftheuterus,endometrialhyperplasia,uterineinfection,oran endometriumthatistoothin Considerations.Endometrialablationsignificantlydecreasesthelikelihoodawomanwillbecomepregnant.However, pregnancycanstilloccurandthisprocedureincreasestherisksofcomplications,includingmiscarriage.Womenwho havethisproceduremustbecommittedtonotbecomingpregnantandtousingbirthcontrol.Sterilizationafterablationis anotheroption.

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Amainconcernofendometrialablationisthatitmaydelayormakeitmoredifficulttodiagnoseuterinecancerinthe future.(Postmenopausalbleedingorirregularvaginalbleedingcanbewarningsignsofuterinecancer.)Womenwho haveendometrialablationstillhaveauterusandcervix,andshouldcontinuetohaveregularPapsmearsandpelvic exams. TypesofEndometrialAblation.Endometrialablationusedtobeperformedinanoperatingroomusingelectrosurgerywith aresectoscope(ahysteroscopewithaheatedwirelooporrollerball.)Laserablationwasanotherolderprocedure. Thesetypesofendometrialablationhavelargelybeenreplacedbynewertypesofprocedurethatdonotusea resectoscope. Thenewerprocedurescanbeperformedeitherinanoperatingroomoradoctorsoffice.Theyinclude: Radiofrequency.TheNovaSuresystemusesameshelectrodeprobethatemitselectromagneticenergytodestroy thelining. Heatedfluid.IntheHydroThermAblatorsystem,asalinesolutionisinsertedintotheuteruswithahysteroscope andheateduntiltheliningisdestroyed.Inthethermalballoonmethod,aballooninsertedintotheuteruswith hysteroscopeisfilledwithheatedfluidandexpandeduntilittouchesanddestroystheendometrium. Freezing.Cryoablationusesliquidnitrogentofreezetheuterinelining. Microwave.Microwaveendometrialablationappliesverylowpowermicrowavestotheuterus. BeforetheProcedure.Inpreparingfortheablationprocedure,thedoctorwillperformanendometrialbiopsytomakesure thatcancerisnotpresent.Ifthewomanhasanintrauterinedevice(IUD),itmustberemovedbeforetheprocedure.In somecases,hormonaldrugs,suchasGnRHanalogs,maybegivenafewweeksbeforeablationtohelpthinthe endometriallining. DuringtheProcedure.Endometrialablationisanoutpatientprocedure.Thedoctorusuallyappliesalocalanesthetic aroundthecervix.(Thepatientalsoreceivesmedicationforpainandtohelpherrelax.)Thedoctorwilldilatethecervix beforestartingtheprocedure.Patientsmayfeelsomemildcrampingordiscomfort,butmanyofthenewertypesof endometrialprocedurescanbeperformedinunder10minutes. AftertheProcedure.Patientsmayexperiencemenstruallikecrampingforseveraldaysandfrequenturinationduringthe first24hours.Themainsideeffectiswateryorbloodydischargethatcanlastforseveralweeks.Thisdischargeis especiallyheavyinthefirstfewdaysfollowingablation.(Patientsneedtowearpads,nottamponsduringthistime,andto waittohavesexuntilthedischargehasstopped.)Patientsaregenerallyabletoreturntoworkornormalactivitieswithina fewdaysaftertheprocedure. Complications.Complicationsofendometrialablationmayincludeperforationoftheuterus,injurytotheintestine, hemorrhage,orinfection.Ifheatedfluidisusedintheprocedure,itmayleakandcauseburns.However,ingeneral,the riskofcomplicationsisverylow. Nearlyallwomenhavereducedmenstrualflowafterendometrialablation,andnearlyhalfofwomenhavetheirperiods stop.Somewomen,however,maycontinuetohavebleedingproblemsandultimatelydecidetohaveahysterectomy. Hysterectomy Hysterectomyisthesurgicalremovaloftheuterus.

Clicktheicontoseeanillustratedseriesdetailinga hysterectomy.

Heavybleeding,oftenfromfibroids,andpelvicpainarethereasonsformanyhysterectomies.However,withnewer medicalandsurgicaltreatmentsavailable,hysterectomiesareperformedlessoftenthaninthepast.Initssupport, hysterectomy,unlikedrugtreatmentsandlessinvasiveprocedures,curesmenorrhagiacompletely,andmostwomenare satisfiedwiththeprocedure.Lessinvasivehysterectomyproceduresarealsoimprovingrecoveryratesandincreasing satisfactionafterward. Still,anywomanwhoisuncertainaboutarecommendationforahysterectomytotreatfibroidsorheavybleedingshould certainlyseekasecondopinion. NerveDestructionTechniquesforTreatingDysmenorrhea Someevidencesuggeststhatsurgicallycuttingthepainconductingnervefibersleadingfromtheuterusdiminishesthe painfromdysmenorrhea.Twoprocedures,laparascopicuterinenerveablation(LUNA)andlaparoscopicpresacral

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neurectomy(LPSN),canblocksuchnerves.Somesmallstudieshaveshownbenefitsfromtheseprocedures,butstronger evidenceisneededbeforetheycanberecommendedforwomenwithsevereprimarydysmenorrheaorthechronicpelvic painassociatedwithendometriosis.Manyinsurancecompaniesconsidertheseproceduresexperimentalandwillnotpay forthem.

Resources
www.acog.orgAmericanCollegeofObstetriciansandGynecologists www.resolve.orgNationalInfertilityAssociation www.asrm.comAmericanSocietyforReproductiveMedicine www.endometriosisassn.orgEndometriosisAssociation

References
AmericanAcademyofPediatricsCommitteeonAdolescenceAmericanCollegeofObstetriciansandGynecologists CommitteeonAdolescentHealthCareDiazA,LauferMR,BreechLL.Menstruationingirlsandadolescents:usingthe menstrualcycleasavitalsign.Pediatrics.2006Nov118(5):224550. ApgarBS,KaufmanAH,GeorgeNwoguU,KittendorfA.Treatmentofmenorrhagia.AmFamPhysician.2007Jun 1575(12):18139. CasablancaY.Managementofdysfunctionaluterinebleeding.ObstetGynecolClinNorthAm.2008Jun35(2):21934. ChenEC,DanisPG,TweedE.Clinicalinquiries.Menstrualdisturbancesinperimenopausalwomen:what'sbest?JFam Pract.2009Jun58(6):E3. ChoSH,HwangEW.Acupunctureforprimarydysmenorrhea:asystematicreview.BJOG.2010Apr117(5):50921.Epub 2010Feb17. DamloS.ACOGguidelinesonendometrialablation.AmFamPhysician.2008Feb1577(4):545549. DanielsJ,GrayR,HillsRK,LattheP,BuckleyL,GuptaJ,etal.Laparoscopicuterosacralnerveablationforalleviating chronicpelvicpain:arandomizedcontrolledtrial.JAMA.2009Sep2302(9):95561. GordonCM.Clinicalpractice.Functionalhypothalamicamenorrhea.NEnglJMed.2010Jul22363(4):36571. GuerreraMP,VolpeSL,MaoJJ.Therapeuticusesofmagnesium.AmFamPhysician.2009Jul1580(2):15762. KaunitzAM,MeredithS,InkiP,KubbaA,SanchezRamosL.Levonorgestrelreleasingintrauterinesystemand endometrialablationinheavymenstrualbleeding:asystematicreviewandmetaanalysis.ObstetGynecol.2009 May113(5):110416. LethabyA,IrvineG,CameronI.Cyclicalprogestogensforheavymenstrualbleeding.CochraneDatabaseSystRev.2008 Jan23(1):CD001016. LethabyA,HickeyM,GarryR,PenninxJ.Endometrialresection/ablationtechniquesforheavymenstrualbleeding. CochraneDatabaseSystRev.2009Oct7(4):CD001501. LoboRA.Abnormaluterinebleeding.Ovalutoryandanovulatorydysfunctionaluterinebleeding,managementofacute andchronicexcessivebleeding.In:KatzVL,LoboRA,LentzG,GershensonD,eds.ComprehensiveGynecology.5thed. St.Louis,MO:Mosby2007:chap37. LoboRA.Primaryandsecondaryamenorrheaandprecociouspuberty.Etiology,diagnosticevaluation,management.In: KatzVL,LoboRA,LentzG,GershensonD,eds.ComprehensiveGynecology.5thed.St.Louis,MO:Mosby2007:chap 38. MarjoribanksJ,ProctorM,FarquharC,DerksRS.Nonsteroidalantiinflammatorydrugsfordysmenorrhea.Cochrane DatabaseSystRev.2010Jan20(1):CD001751. MasterHunterT,HeimanDL.Amenorrhea:evaluationandtreatment.AmFamPhysician.2006Apr1573(8):137482. MiddletonLJ,ChampaneriaR,DanielsJP,BhattacharyaS,CooperKG,HilkenNH,etal.Hysterectomy,endometrial destruction,andlevonorgestrelreleasingintrauterinesystem(Mirena)forheavymenstrualbleeding:systematicreview andmetaanalysisofdatafromindividualpatients.BMJ.2010Aug16341:c3929.doi:10.1136/bmj.c3929. [Noauthorslisted]ACOGPracticeBulletinNo.110:noncontraceptiveusesofhormonalcontraceptives.ObstetGynecol. 2010Jan115(1):20618.

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OrtizDD.Chronicpelvicpaininwomen.AmFamPhysician.2008Jun177(11):153542. PracticeCommitteeofAmericanSocietyforReproductiveMedicine.Indicationsandoptionsforendometrialablation. FertilSteril.2008Nov90(5Suppl):S23640. ProctorML,FarquharCM.Dysmenorrhea.ClinEvid.2006Jun(15):242948. SambrookAM,BainC,ParkinDE,CooperKG.Arandomisedcomparisonofmicrowaveendometrialablationwith transcervicalresectionoftheendometrium:followupataminimumof10years.BJOG.2009Jul116(8):10337.Epub 2009May11. SmithCA,ZhuX,HeL,SongJ.Acupunctureforprimarydysmenorrhea.CochraneDatabaseSystRev.2011Jan19 (1):CD007854. SweetMG,SchmidtDaltonTA,WeissPM,MadsenKP.Evaluationandmanagementofabnormaluterinebleedingin premenopausalwomen.AmFamPhysician.2012Jan185(1):3543. WittCM,ReinholdT,BrinkhausB,RollS,JenaS,WillichSN.Acupunctureinpatientswithdysmenorrhea:arandomized studyonclinicaleffectivenessandcosteffectivenessinusualcare.AmJObstetGynecol.2008Feb198(2):166.e18. WongCL,FarquharC,RobertsH,ProctorM.Oralcontraceptivepillforprimarydysmenorrhea.CochraneDatabaseSyst Rev.2009Oct7(4):CD002120.
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