Health Care for Women International, 28:817827, 2007 Copyright Taylor & Francis Group, LLC ISSN: 0739-9332

2 print / 1096-4665 online DOI: 10.1080/07399330701563178

The Etiology of Some Menstrual Disorders: A Gynecological and Psychiatric Issue

HELEN SHEINFELD
Talbieh Psychiatric Hospital, Hebrew University-Hadassa Medical School, Jerusalem, Israel

MICHAEL GAL
Obstetric and Gynecology Department, Share-Zedek, University Ben-Gurion, Jerusalem, Israel

MICHAEL E. BUNZEL
Division of Psychiatry, Sheba Medical Center, Ramat Gan, Israel

TALI VISHNE
Beer-YaacovNess-Ziona Mental Health Center, Ness-Ziona, Israel

Some menstrual disorders with distinct gynecological character such as amenorrhea or menometrorrhagia (MMR) may have psychogenic etiology. On the other hand, in menstrual psychosis (MP), a distinctly psychiatric disorder, the etiology is not necessarily psychogenic, but rather is hormonalbiological. We present 4 cases, one each of primary and secondary amenorrhea, MMR, and MP, respectively. In the rst 3 cases (2 amenorrhea and 1 MMR), we found psychogenic factors: an insult to feminine development after rape (case 1) or marriage problems (cases 2 and 3). In the case of a recurrent MP, no relevant psychological etiology was found. Furthermore, some of the patients relatives had menstrual or peripartum psychiatric disorders. Menstrual disorders etiology can be psychogenic or hormonal. The correct etiology is the guide for the adequate therapeutic way: psychotherapy based in psychogenic disorders and neuroleptic or antiovulatory drugs in those of biological etiology. Some menstrual disorders with distinct gynecological character such as amenorrhea or menometrorrhagia (MMR) may have psychogenic etiology. On the other hand, in menstrual psychosis (MP), a distinctly psychiatric disorder, the etiology is not necessarily psychogenic, but hormonalbiological.
Received 5 December 2005; accepted 9 September 2006. Address correspondence to Tali Vishne, 25 Begin St., Givat Shmuel 54421, Israel. E-mail: tali@vishne.com 817

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We present 4 cases, one each of primary and secondary amenorrhea, MMR, and MP, respectively. The uniqueness of our description lies in the special population from which the cases are collectedall 4 are ultraorthodox women, with unique attitudes toward the menstrual cycle. Amenorrhea can be primary (PA) or secondary (SA). PA is dened as lack of menstrual cycles until the age of 16. If no secondary sexual signs exist, PA can be dened at the age of 14. The prevalence of PA is 0.1%2.5%. Diagnosis should include exclusion of organic factors such as imperforated hymen, Mullerian dysgenesis, Turners syndrome, and other primary dysgenesis of the female apparatus. Hyperandrogenism, hypophysiss diseases, proliferative processes, bad nutrition and signicant loss of weight, exaggerated physical activity, stress, and prolactin increasing substances may be organic etiological factors of both PA and SA. SA is dened as the lack of menstrual cycles for a period of 6 months or more in a woman with previously regular menstrual cycles. The prevalence of SA is about 4%. A woman older than 40 with high follicle stimulating hormone (FSH) is dened as menopausal, while a woman below 40 will be dened as having early ovarian failure. The ovulation and menstrual cycles are based on the function of the hypothalamus, pituitary gland, the ovaries, the uterus, and the interrelations between all these factors. Renal or parathyroid disorders may cause amenorrhea. In the absence of organic ndings, psychogenic amenorrhea should be considered. Psychogenic primary amenorrhea (PPA) and psychogenic secondary amenorrhea (PSA) also are called stress, functional, or hypothalamic amenorrhea. These names refer to deciency of the supervision of the hypothalamus on other related compartments. In general, PPA received less attention than PSA, but during the late 1950s, two studies were published about these subjects (Joel & Lancet, 1956, 1958). In the rst, the authors presented a 27-year-old woman who got her spontaneous rst menstrual cycle during the diagnosis process. The authors speculated that the reasons for the amenorrhea as well as for the rst menstrual cycle were both psychogenic. Psychogenic secondary amenorrhea (PSA) was referred to as stress amenorrhea as early as in 1797 (Buchan, 1977). It was related to life events such as enlistment (Drillien, 1946), entering a boarding school (McCornick, 1975), entrance to monastery (Drew & Stifel, 1968), or as a result of excessive physical exercise (Dusek, 2001; Warren & Shantha, 2000). The prevalence of PSA rises in stress situations such as war or disasters. It is important to distinguish between two types of PSA (Schoenfeld, Amir, Lichtenberg, & Gaulayev, 1990): one is related to nonspecic stress situations, namely, not related to feminine role, as those mentioned above. In these cases the disorder is mild, and it tends to disappear within a short period of time with the adjustment to the new situation or with the end of it. This type of psychogenic amenorrhea usually happens to basically

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normal women. The other type is related to a specic insult to femininity during one of the sexual development stages or even later, or as a solution to problematic couple relationships. In these cases, the disorder tends to be obstinate and prolonged. Hormonal treatment is not effective, and the patient needs psychological treatment. Hypnosis was found effective for this kind of PSA (Tschugguel & Berga, 2003; Van der Hart, 1985). As far as we know, no case of PSA as a result of marriage problems, as presented in case 2, was previously documented. Menorrhagia is over 7 days or over 80 ml of menstrual bleeding. Metrorrhagia is an irregular bleeding occurring during the menstrual cycle. These are the two types of abnormal bleeding. Menometrorrhagia (MMR) is a combination of those two disorders. Organic reasons for pathological bleeding include hormonal imbalance, especially between estrogen and progesterone, pelvic infections, broid uterus, infections and uterus malignancies, prostaglandins imbalance, injuries, dilatators, intrauterine device (IUD), homeostatic problems, endometriosis, hypothyroidism, and iron deciency. When no organic reason is found, the option of psychogenic MMR (PMMR) should be considered. This disorder was more prevalent among women under psychological stress (Shapley, Jordan, & Croft, 2002, 2003). Previous articles referred in more detail to the psychogenic etiology of PMMR. In a report on 9 cases, Blaikley (1960) suggested that certain women choose menorrhagia as a way to deal with a stressful situation, such as marital problems. Interestingly, the author, an obstetric surgeon, suggested the emotional etiology and even performed some of the psychological interventions. A psychotherapist reported in 1960 that the symptom appeared in women with a high neurotic level (ONeill, 1960), and, in 1983, a study on 50 women with metrorrhagia found depression in 31 (Greenberg, 1983). Menstrual psychosis (MP) is different from the schizophrenic psychosis in three important features: First, it has a cycling character. It appears adjacent to the menstrual bleeding and passes a short period afterward. Second, when over, the patient is in full remission, and, third, the disease does not cause deterioration. The prognosis is good. The disease is not necessarily accompanied by schizophrenic atmosphere. This expression is taken from the German psychiatric terminology and was used to describe psychotic reactions to emotional trauma (Labhardt, 1969). In MP, the reactive element often is missing. Due to its cyclic character, MP is considered one of the cycloid psychoses (CP), that is, recurrent psychoses that are not part of a schizophrenia and do not cause deterioration. The term CP is related to the German psychiatrist Karl Leonhard (19041988). Carl Wernicke and Karl Kleist, also from the German school studied the subject but are less connected to it. The polymorphous symptoms that were described in this entity included hyperkinesis or akinesis, loose associations, anxiety, happiness and ecstasy,

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confusion, paranoid delusions, hallucinations, misidentication of persons, and global altruism (Jonsson, Jonson, & Nyman, 1991; Pfuhlmann, 1998). Since the MP occurs in the luteal phase, a question has to be asked: What is the bond between the psychotic development and this phase of the menstrual cycle? In a paper about CP Jabs and colleagues (2002, p. 912), quote an interesting study that included 155 women with acute psychiatric disorders. In the group of patients diagnosed with CP, the percentage of patients with psychosis onset in the luteal phase was signicantly higher as compared with women with other diagnoses. It is possible that women whose disease started at the luteal stage are biologically more susceptible to hormonal uctuations of this stage. Usually, MP presents itself during puberty, with the rst or one of the rst menstrual cycles. The psychotic vulnerability of this period has been known for a long time. I. Kant (17241804) referred to it as adolescent insanity, in which the sensus comunis is replaced by sensus privates (Lehmann, 1968). In an attempt to explore adolescents tendency to psychoses, researchers from Emory University explored the hormones and neurotransmitters changes that are characteristic of this period of life and their inuence on an adolescents brain (Walker & Bollini, 2002). They found decreased serotonergic and increased dopaminergic activity prominent in the cortical areas of the brain, especially in the frontal lobe. These ndings can explain the tendency to mental disorders, especially psychosis, during adolescence. The biological etiology of MP is related to estrogen, progesterone, serotonin, and dopamine, which are the main neuroendocrinological setting of it. Between these substances, and between them and other biological systems, there are many interactions, as was found in studies from recent years (Bethea, Pecins-Thompson, Schutzer, Gundlah, & Lu, 1998; Yu & Liao, 2000; Chakravorty & Halbreich, 1997; Lambert, Belelli, Peden, Vardy, & Peters, 2003; Follesa, Biggio, Caria, & Biggio, 2004; Dazzi et al., 2002; Hochman & Lewine, 2004; Huber et al., 2001; Kulkarny et al., 2001; Fink, Sumner, Rosie, Grace, & Quinn, 1996). The sensitivity of the brain to hormonal imbalance or uctuations is different from one woman to another. In addition we must bear in mind that increased activation of HPA by stress may increase the danger for MP in vulnerable individuals. It is possible that MP is one of the forms of feminine psychoses. The other form is puerperal psychosis (Deuchar & Brokington, 1998; Mahe & Dumaine, 2001). It also can be part of a pathological continuum that includes other menstrual disturbances like premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). All cases described in the current study focus on psychomenstrual disturbances in an ultraorthodox population. This special population adds to the uniqueness of the cases that are described here. It also adds to the ambiguity about the interrelation among culture, psychology, and

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physiology. International interdisciplinary audience may nd it interesting to reveal similarities and differences in these problems in other cultures and population with different attitudes toward femininity.

CASE STUDIES Case 1. PPA as a Result of Disturbed Feminine Process Following Rape
A, 19.5 years old, one of two homozygous twins, was raised in an orthodox Jewish family. She turned to psychiatric treatment due to primary amenorrhea. A gynecological evaluation at the age of 17 revealed a normal but undeveloped anatomical reproductive system and low hypophysarian and ovarian hormonal activity. No other relevant organic ndings were present. She was suggested to take hormonal intervention, which her parents asked to postpone. At the age of 14, A was raped by a foreign man. After the rape, she had a short psychological intervention of three meetings. As twin sister had her rst menstrual cycle at the age of 14.5. She married at the age of 19 and already was pregnant. A was tall and thin, with no secondary feminine signs. Except for some adequate embarrassment, no emotional or psychological symptoms were found in the clinical evaluation. Due to diagnosis of PPA, a psychotherapeutic intervention was performed that focused on the rape trauma and femininity. Five months later, and with regular once-a-week meetings, A had her rst menstruation. Slowly evident body feminine developmental signs were shown, and about 7 months after the beginning of the treatment A agreed for the rst time to meet with a man for matchmaking purposes. The treatment lasted 8 months, and was terminated when A became engaged. At the end of the psychotherapeutic intervention, she had regular menstrual cycles.

Case 2. PSA as a Defense Against the Sin of Sexual Relationship During Menstrual Bleeding
S, 36 years old, is an orthodox Jewish woman, married and a mother of three. Her husband had recurrent manic episodes, in which he forced her to have sexual intercourse with him even during her menstrual bleeding. After several horrifying months, S escaped from home, but she was forced to return by her husband. The husbands manic episodes lasted due to his noncompliance with treatment. About 6 months after the beginning of the manic attacks, in one of her husbands follow-up meetings, S told her husbands therapist that for the last 3 months her menstrual cycle ceased. She was just mentioning a fact, not as a complaint and not for the purpose of treatment or evaluation.

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Furthermore, it seemed that the phenomenon made her feel relieved and not annoyed. For that reason, no tests and no gynecological evaluation were performed. Currently, S is in her thirteenth year of amenorrhea.

Case 3. PMM as a Solution to Marital Problems

R, 30 years old, is a wife of a rabbi 3 years older than she and a mother of four children (10, 8, 6, 2 years old) She was referred to a psychiatric community clinic due to menometrorrhagia from which she suffered for the last 10 months. Since she was 13 when she had her rst menstrual cycle, and until recently, her menstrual cycles were regular. She never used contraceptives, and her pregnancies and deliveries were normal. Before being referred to the clinic, R had a thorough medical evaluation including gynecological, thyroid, and systemic evaluation. No pathology was revealed, except for anovulatory cycles. Hematological examination revealed mild iron deciency anemia. Regular coagulation tests were normal. R looked t for her age. She was good looking and well-dressed, somewhat pale. She complained of headaches, tiredness, and numbness of her palms. Neurological examination was normal. R was raised in a warm family, the oldest of three children. She was deeply attached to her parents and to the rest of the family, who helped her with her daily obligations and with raising her children. A year prior to the development of the symptoms described above, her husband was offered a position in a foreign country, which he postponed for 1 year at the request of R. In the three intake meetings we learned that R had difculty accepting the possibility of traveling away from home, being afraid to lose close contact with her primary family. R also was afraid of another pregnancy, for which she felt she was not yet ready. She could not confess to her husband, being afraid to be considered an unfaithful woman. We felt that these circumstances could t psychogenic etiology, and psychotherapy was offered. At that stage, R gave new information: A rst-degree cousin had suffered from Von Willebrand disease. Specic hematological tests performed at that time failed to nd Von Willebrand antigen factor. R did not agree to be treated in community clinic, but she did attend private psychotherapy.

Case 4. A Case of MP
M, 16 years old, is the fourth of 7 children. She was brought to treatment suffering from severe psychomotor agitation, incoherence, affective instability, crying, fears, confusion, complaining of weird feeling toward the oor both visual and while walking. She also found it hard to recognize her own

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face and the faces of her beloved ones (prosopagnosia, in neurological term) and showed misidentication of familiar persons. Five days prior to her visit, she had her rst menstrual cycle. Two days before bleeding, she experienced the visual and proprioceptive delusions, suffered from insomnia, and gradually the other noticeable psychotic symptoms had appeared. During the 3 days prior to her visit, she received (from another psychiatrist) 1 mg per day of risperidone and 0.5 mg per day of clonazepam. The parents, described as warm and dedicated, transferred the girl outside of town in order to save her from the disgrace of neighbors. The girl experienced this as frightening, and this by itself probably worsened her condition. With treatment, the dosage of risperidone was raised to 2 mgs per day, and the clonazepam was switched to thioridazine 2030 mgs per day. She returned home. Some days afterward, her condition gradually improved. She returned to school 10 days afterward under the treatment of risperidone 1 mg per day. Prolactin levels measured during treatment were 866 mlu/l (superior normal level 619 mlu/l). The next menstrual bleeding was 3 months after the rst menstrual cycle, and 6 weeks after cessation of medications. Several days before the menstrual bleeding, she reported insomnia that passed without psychiatric or other medical intervention. Thirty days afterward, she had another menstrual bleeding, during which she felt weird feelings toward the oor, and within several days acute psychosis developed, yet less severe than the rst one. In this time, M was more aware of her situation. The treatment with risperidone was renewed, with dosages up to 2 mgs per day. Six days later she was improved and gradually she returned to normal functioning. Today, a year and a half later, she continues taking 1 mg per day of risperidone. She refuses to lower the dosage due to fear of another occurence. During this period she did not have any psychotic symptoms. Her menstrual cycles are regular. She was offered an antiovulation treatment, but her parents refused, being afraid it will interfere with her becoming engaged to be married. About 6 months after M attended the clinic, her sister P, 15 years old, started suffering from back pain, and her mother prepared her for her upcoming rst menstruation. She started having weird feelings toward the oor and visual perceptive delusions toward people faces. Still, she was organized, and therefore it was decided to prescribe low-dose risperidone (1 mg per day). Except for a short period, she continued functioning normally. One year afterward, she is still on 0.5 mg per day of risperidone. P has light perceptive disorder toward the oor with full insight, that is, she understands that her perception is misleading. She did not have her menstrual cycle yet. After a gynecological consultation, a hormonal antiovulatory therapy was excluded due to the risk of impairing the development of the reproductive system. Her good psychiatric condition and the low risperidone dose

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supported the decision. P is not treated at the moment, except for followup at the family physician. The mother (45) of the two sisters has perceptive proprioceptive disorder toward the oor in the days before her menstrual bleeding since her rst menstrual cycle at the age of 15. She never had psychiatric treatment. Another daughter has PMDD, and yet another one suffered two bouts of postpartum agitated depression.

DISCUSSION
Attitudes toward the menstrual period are affected by cultural background (see, for example, Chandra & Chaturvedi, 1992; Hoerster, Chrisler, & Rose, 2003). Negative attitudes toward menstrual cycle bleeding, as well as strong psychological reactions toward the bleeding exceeding its physiological role are evident in Western, Muslim, and Jewish traditions (Whelan, 1975). In Jewish tradition, which is the focus of this work, the menstrual cycle days dene the woman as unclean, which may lead to negative feelings toward menstrual bleeding (Siegel, 19851986). Furthermore, young Jewish religious women were found to believe that the menstrual period is painful and limiting, and a few also believed that during their period they should not prepare food, handle a holy book, or go to the synagogue (Brooks, 1984). All of those attitudes could be related to the physiological reactions to menstruation. The etiology of menstrual disorders can be psychogenic, such as in some cases of primary amenorrhea (case 1) or secondary amenorrhea (case 2) or in cases of pathological bleeding (case 3). In psychogenic amenorrhea, thorough gynecological and endocrinological examination can enhance diagnosis, since in many such cases an undeveloped reproductive system or pituitary and ovarian lower function, or both will be found, as in our case 1. Psychiatric evaluation can further complete the diagnosis if the impression is that psychogenic factors can explain the disorder. In case 2, the case of secondary amenorrhea as a solution to illicit sexual relations during menstruation, no thorough diagnosis was performed to explain the phenomena and no treatment was suggested because the woman did not complain about the symptom, but rather beneted from it. The psychogenic etiology is based on the circumstances, the clinical impression, and the continuation of the symptom over 13 years without any medical complication. In cases of psychogenic pathological bleeding, no specic gynecological or endocrinological ndings are expected, but they are meant to exclude organic etiology. The psychiatric evaluation has a signicant role in the etiological diagnosis, as seen in case 3. In the case of menstrual psychosis in which no signicant psychogenic components are found, we assume that there is some hormonal imbalance combined with biological brain sensitivity and there may be a genetic

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tendency toward psychosis. The diagnosis will be based on the time of onset, adjacent to the menstrual bleeding, its cyclic character, and its remission. While a woman is in psychogenic amenorrhea and bleeding, psychotherapy is the treatment of choice, in menstrual psychosis the treatment of choice is (antipsychotic) neuroleptics or hormonal therapy to avoid ovulation. The treatment choice, neuroleptic versus hormonal therapy, is done based on the case and on side effects of each of the treatment modalities. The existence of several types of feminine disorders, such as menstrual psychosis in different stages of severity, PMDD, and postpartum psychiatric disorders in one family (case 4), may point out a geneticfamilial tendency and the possibility of pathological continuum. Cooperation between gynecologists and psychiatrists is crucial for diagnosis of etiology and treatment choice.

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