The etiology of some menstrual disorders: a gynecological and psychiatric issue

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 hormonal-biological. We present 4 cases, one each of primary and secondary amenorrhea, MMR, and MP, respectively. In the first 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 patient's 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.     

抗精神病药与高催乳素血症及月经紊乱

抗精神病药(APS)可被分为典型APS和非典型APS。高催乳素血症(HPRL)表现为外周血循环中催乳素水平异常增高。所有典型APS与非典型APS中的利培酮，均可导致女性精神疾病患者血清催乳素水平较正常值显著升高。多数非典型APS仅导致血清催乳素水平短暂、轻微增高，甚至对血清催乳素水平无影响。APS所致HPRL是导致女性精神疾病患者月经紊乱，甚至闭经的主要原因之一。目前针对APS所致HPRL及月经紊乱、闭经治疗的主要措施为降低催乳素水平。不同APS所致HPRL及月经紊乱发生率不同，临床准确评估和管理HPRL，可提高女性精神疾病患者的生活质量及治疗依从性。笔者拟就APS治疗女性精神疾病患者时导致的HPRL与月经紊乱不良反应的处理进行阐述，以期为临床降低该类患者的不良反应提供参考。     

Effect of levonorgestrel-releasing intrauterine device on hormonal profile and menstrual pattern after long-term use

In the present study 14 women after 6 years' use of levonorgestrel-releasing IUD were investigated for the changes of LH, progesterone (P), estradiol (E₂), prolactin (PRL) and serum binding globulin (SHBG) in relation to the levonorgestrel levels throughout a segment of 26–40 days with the aim of comparing the hormonal profiles with those during the first year of use of Lng-IUD. Ultrasound scanning was used to follow the development of follicles along with the RIA measurement of hormones. The results of serum LH, P and E₂ showed ovulation in 11 cases with either normal menstrual cycles (5 cases), prolonged or irregular cycles (4 cases) or with amenorrhea for 2–3 years (2 cases). One case showed insufficiency of luteal function and 2 cases showed anovulation but with follicular hyperactivity. Higher percentages of ovulatory cycles (78.5%) were found after 6 years of use. No case of complete suppression of ovulation was found. Anovulatory cycles only constituted 14.3%. Clinically, the development of follicles followed by ultrasound scanning further confirmed the hormonal findings. The persistent enlargement of follicles coincided with high levels of E₂. After 6 years of use, the serum levels of levonorgestrel were still maintained at mean levels of 314.26 pmol/L and 470.63 pmol/L in the ovulatory and anovulatory groups, respectively. It is concluded that over two-thirds of the cases have ovulatory cycles after long-term use of Lng-IUD; the contraceptive effect is mainly due to its local action on the endometrium, with much less effect on the ovarian function.     

The influence of stress on the menstrual cycle among newly incarcerated women.

OBJECTIVE: We sought to estimate the association of stressful life events on menstrual function in incarcerated women. METHODS: Project CONNECT is a study of reproductive health needs of incarcerated women conducted between June 2002 and December 2003. This analysis examines menstrual function in 446 women from this cohort who were under the age of 45. Regularity was defined as menses between 26 and 35 days long. Amenorrhea was defined as > or =90 days since last menstruation. Measures included stressful experiences and deprivation (e.g., physical or sexual abuse, stressful living conditions, exchanging sex for drugs or money, or having had an incarcerated parent). RESULTS: Menstrual dysfunction was common in this population. Nine percent reported amenorrhea, and 33% reported menstrual irregularity. A number of stressors were associated with menstrual irregularity, including having a parent with history of alcohol or drug problems (relative risk [RR] = 1.34; 95% confidence interval [CI], 1.00-1.80), childhood physical or sexual abuse (RR = 1.48; 95% CI, 1.03-2.13), or any sexual abuse (RR = 1.49; 95% CI, 1.03-2.14) after adjusting for age, race/ethnicity, smoking status, and recent drug use. These effects were attenuated somewhat when excluding women who had reported any hormonal contraceptive use in the past 3 months. CONCLUSION: Incarcerated women have high rates of amenorrhea and menstrual irregularity and the prevalence may be associated with certain stresses. Further research on the causes and consequences of menstrual dysfunction in this underserved population is needed.     

Menstrual irregularity from hormonal contraception: a cause of reproductive health concerns in minority adolescent young women

CONTEXT: Adolescents are frequent users of hormonal contraception (HC), yet their adherence to these methods is often poor. Concerns about side effects, especially those affecting the menstrual system, are often given as reasons for contraceptive nonadherence or discontinuation. We sought to identify teens' concerns and misperceptions about the menstrual-related side effects of HC. METHODS: Open focus groups were conducted with both sexually active and virgin adolescent women aged 12-18 years who were recruited from the Philadelphia area. The adolescents did not have to be contraceptive users in order to participate. The question put to each group was, "What are the things you have heard about the birth control pill, Depo-Provera and Norplant?" Groups were audio-recorded, transcribed and analyzed using qualitative software. RESULTS: We conducted 13 female-only groups. Participants raised frequent concerns about menstrual-related side effects, believing that these side effects were evidence of possible negative effects of HC on their reproductive health. Four themes related to hormonal contraceptive-induced menstrual irregularity emerged from the groups. Theme 1: Menstruation is natural and should not be altered in any way. Theme 2: The menstrual period is necessary for cleansing of the body. Theme 3: "Spotting," intermenstrual bleeding and amenorrhea cause doubts about the method's effectiveness and worries about pregnancy. Theme 4: All menstrual irregularity, from intermenstrual bleeding to amenorrhea, causes worry about the effects on fertility and on physical health. CONCLUSIONS: Teens have concerns about the menstrual irregularity caused by HC. Providers understand that these side effects are minor and of little medical consequence. Yet, adolescent patients may be ascribing great significance to these effects and may be declining these methods because of fear and misperceptions.     

Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review

BackgroundWomen with depressive or bipolar disorders are at an increased risk for unintended pregnancy.ObjectiveTo examine the safety of hormonal contraception among women with depressive and bipolar disorders.MethodsWe searched for articles published through January 2016 on the safety of using any hormonal contraceptive method among women with depressive or bipolar disorders, including those who had been diagnosed clinically or scored above threshold levels on a validated screening instrument. Outcomes included changes in symptoms, hospitalization, suicide and modifications in medication regimens such as increase or decrease in dosage or changes in type of drug.ResultsOf 2376 articles, 6 met the inclusion criteria. Of three studies that examined women clinically diagnosed with depressive or bipolar disorder, one found that oral contraceptives (OCs) did not significantly change mood across the menstrual cycle among women with bipolar disorder, whereas mood did significantly change across the menstrual cycle among women not using OCs; one found no significant differences in the frequency of psychiatric hospitalizations among women with bipolar disorder who used depot medroxyprogesterone acetate (DMPA), intrauterine devices (IUDs) or sterilization; and one found no increase in depression scale scores among women with depression using and not using OCs, for both those treated with fluoxetine and those receiving placebo. Of three studies that examined women who met a threshold for depression on a screening instrument, one found that adolescent girls using combined OCs (COCs) had significantly improved depression scores after 3 months compared with placebo, one found that OC users had similar odds of no longer being depressed at follow-up compared with nonusers, and one found that COC users were less frequently classified as depressed over 11 months than IUD users.ConclusionsLimited evidence from six studies found that OC, levonorgestrel-releasing IUD and DMPA use among women with depressive or bipolar disorders was not associated with worse clinical course of disease compared with no hormonal method use.     

Gynecologic and endocrinologic sequelae of bulimia--hormonal changes

INTRODUCTION: Gynecological problems are one of the most frequent somatic complications of eating disorders. AIMS: The purpose of the present study was to assess the role of improper eating habits causing menstrual disturbances, anovulation and related hormonal changes. Latent bulimia nervosa is in the focus of attention since amenorrhea is considered as a diagnostic criterion of anorexia nervosa. METHOD: Subjects of the BITE (Bulimia Investigation Test, Edinburgh) test were infertile patients (n = 34) of the gynecological outpatient departments after medical examination, blood-test (LH, FSH, androstenedione, DHEAS, progesterone, testosterone, SHBG, prolactin) and ultrasonic examination (uterus and ovaries). RESULTS: Symptoms and severity subscales of the BITE test and body mass index (BMI) were close correlation (p = 0.003, p = 0.033). In comparison with previous results, EDNOS (Eating Disorders Not Otherwise Specified) prevalence was 48%. Of hormonal changes, low LH and FSH levels (6/6) and hyperandrogenism (5/6) were significant in patients with subclinical eating disorders (n = 6) by infertile women as compared with the "normal" infertile group (n = 18; 7/18, 8/18). CONCLUSION: The recent results suggests that unsatisfactory nutrition (bulimic binges, "crash diet") is as relevant in hormonal dysfunction, menstrual disturbances and infertility as pathologically low weight in anorexia nervosa. Excessive application of contraceptives in therapy has to be taken into consideration.     

Patterns of menstrual disturbance in eating disorders

OBJECTIVE: To describe menstrual disturbance in eating disorders (ED). METHOD: We describe menstrual history in 1,705 women and compare eating, weight, and psychopathological traits across menstrual groups. RESULTS: Menstrual dysfunction occurred across all eating disorder subtypes. Individuals with normal menstrual history and primary amenorrhea reported the highest and lowest lifetime body mass index (BMI), respectively. Normal menstruation and oligomenorrhea groups reported greater binge eating, vomiting, and appetite suppressant use. Amenorrhea was associated with lower caloric intake and higher exercise. Harm avoidance, novelty seeking, perfectionism, and obsessionality discriminated among menstrual status groups. No differences in comorbid Axis I and II disorders were observed. CONCLUSION: Menstrual dysfunction is not limited to any eating disorder subtype. BMI, caloric intake, and exercise were strongly associated with menstrual function. Menstrual status is not associated with comorbidity. Menstrual irregularity is an associated feature of all ED rather than being restricted to AN only.     

Amenorrhea rates and predictors during 1 year of levonorgestrel 52 mg intrauterine system use

Objective

The objective was to evaluate amenorrhea patterns and predictors of amenorrhea during the first year after levonorgestrel 52 mg intrauterine system (IUS) placement.

Menstrual cycle length disorders in 18- to 40-y-old obese women

OBJECTIVE: The objective of this study was to measure the relation between menstrual cycle length disorders and degree of obesity. METHODS: We enrolled 120 obese patients ages 18 to 40 y from an outpatient obesity clinic in a cross-sectional study. Patients with polycystic ovarian syndrome were excluded. Obesity was classified in five grades by relative weight. Waist-to-hip ratio was measured and comorbidities were assessed in each patient. Patients were asked to record menstrual cycle characteristics for 3 mo. Logistic regression analysis was performed, with age and type 2 diabetes as confounding variables. The patients' mean age was 29.9 +/- 6.4 y, the mean relative weight was 159.2 +/- 26.6%, and the mean waist-to-hip ratio was 0.84 +/- 0.1. RESULTS: Twenty-two (18.3%) patients had oligomenorrhea and 14 (11.7%) had amenorrhea. The risks for amenorrhea and oligomenorrhea were increased twofold by each unit increase of obesity grade. The odds ratio by waist-to-hip ratio tertile was not statistically significant. Type 2 diabetes and glucose intolerance were statistically significantly associated with amenorrhea and oligomenorrhea. CONCLUSIONS: Higher obesity grades were associated with higher probabilities of menstrual cycle disturbances such as amenorrhea and oligomenorrhea in this group of Mexican women.     

The Relationship between Psychopathology and the Menstrual Cycle

Higher rates of mental ill-health, particularly mood disorder, have been reported in women compared to men and this discrepancy has been attributed to underlying biological changes associated with the menstrual cycle. The literature relating to psychiatric ill-health and the premenstrual syndrome is, accordingly, critically evaluated and the evidence favouring a causal role for menstrual cycle changes in the genesis of such ill-health is briefly reviewed. A simple model of causation attributing psychiatric-illhealth to hormonal variation in the menstrual cycle is eschewed in favour of a multifactorial model which assumes an interaction between hormonal and hormonally-related changes in the premenstruum, basic personality and social dissatisfactions, adverse life circumstances, and interpersonal stresses.     

Menstruation: choosing whether...and when

For many women in the United States, menstruation is a major health concern because menstrual disorders and other conditions that may be aggravated during menses (e.g., migraine headaches, epilepsy) carry substantial morbidity. Women today menstruate nearly 3 times as often as in primitive societies, and evidence suggests that frequent, repetitive menstrual cycles may increase health risks. Because the conventional 21/7 combination oral contraceptive (OC) regimen provides only limited relief for women with menstrual disorders, alternative OC regimens that reduce menstrual frequency have been proposed. A new OC formulation specifically designed to decrease menstrual bleeding to 4 times per year is currently under investigation. Most women welcome less frequent menses or even amenorrhea. Women who may derive particular benefit from reduced menstrual frequency include not only those with medical conditions directly caused or aggravated by menses, but also those serving in the military, female athletes, mentally-retarded women with menstrual hygiene problems, young teens, and perimenopausal women.     

月经过少闭经溢乳症60例临床观察

目的 :探讨用溴隐亭治疗月经过少、闭经、溢乳症的临床效果 ,以及溴隐亭的治疗用量及疗程。方法 :回顾分析总结 1995～ 2 0 0 0年诊治 6 0例月经过少、闭经、溢乳症的临床资料 ,用溴隐亭治疗 ,先从小剂量 1.2 5 mg/日治疗 1周 ,第 2周开始增加剂量至 2 .5 mg/日 ,第 3周 5 mg/日 ,症状改善后逐渐减量 ,至少量 1.2 5 mg/日维持 1～ 1.5月。结果 :经用溴隐亭治疗后 ,3例垂体微腺瘤者症状消失 ,月经来潮 ;11例月经过少 ,3例治疗后 2～ 8周月经量增多 ,3例治疗 4～ 12周妊娠 (其中 2例为高PRL) ;5 1例溢乳患者 ,4 7例治疗后溢乳停止 ,4例明显减少 ;继发不孕 10例 ,治疗期间妊娠 6例 (其中 4例为高 PRL) ,治疗后妊娠 1例。结论 :溴隐亭是药物治疗垂体泌乳素瘤的首选有效药物 ,对高 PRL引起的月经量少、闭经及不孕治疗效果好 ,对某些不明原因的乳房溢乳、继发不孕可考虑使用溴隐亭治疗。     

Endocrinological studies in two patients with post contraceptive cyclic dysfunction

Serial assays of urinary estrogens, pregnanediol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH), WERE PERFORMED IN 2 NORMAL women who developed amenorrhea as a result of oral contraceptive use. Case 1, a woman aged 28 with 2 children took Ovulen (mestranol .1 mg and ethynodiol diacetate 1.0 mg) for 25 months followed by a substitution of chlormadinone acetate (.5 mg per day) when she developed increased menstrual irregularity. Following withdrawal of the medication, vaginal bleeding began and lasted 4 days, and she experienced regular cycles for the subsequent 2 years. The second woman aged 21 developed amenorrhea after 17 months' use of Gynovlar (ethinyl estradiol .05 mg and norethistrone acetate 3.0 mg). Amenorrheic for 21 months at the time of investigation, she was given clomiphene citrate for 5 days (50 mg/day). Further treatment with clomiphene and Pergonal (Serono-Rome) was necessary to resume normal cycles and permit conception which led to full term delivery. Estrogen levels were similar to those of the follicular phase of the normal menstrual cycle; however, they rose spontaneously to midcycle levels in case 1 and as a result of clomiphene treatment in case 2. FSH levels were normal but failed to show consistent patterns; LH patterns were highly irregular in both cases. The findings are consistent with the hypothesis that longterm therapy by oral contraceptives may cause irregular cyclic release of gonadotrophins at the hypothalamic level resulting in amenorrhea and anovulation.     

继发性高促性腺激素闭经的病因与临床表现的异质性——附245例病历分析

目的探讨继发性高促性腺激素闭经(SHA)的病因与表现的异质性(多样性)以及治疗对策。方法回顾性分析245例SHA病历,电话或通信随访到71例,描述其病史、症状、体格检查、实验室、影像学、腹腔镜及骨密度检查指标、治疗和随诊情况。结果病因可能涉及遗传、免疫、手术、放疗、化疗、免疫抑制治疗等医源性因素以及受感染、环境和心理等影响。闭经之前月经形式多种多样,闭经之后7例患者一度恢复自然月经,甚至妊娠。72.7%的患者呈低骨量。结论SHA从病因、病程到临床表现都有明显的多样性,对SHA不要放弃促生育的努力,还应关注其低骨量等健康问题。     

月经失调与甲状腺功能的联系——对1495例临庆系列病例的分析

目的探究月经失调形式和甲状腺功能（甲功）之间的联系。方法系列分析2006年1月4日至2011年3月2日妇科内分泌中心就诊的1495例患者的临床资料,均填写详细病史表格及检测促甲状腺激素、游离三碘甲状腺氨酸与游离甲状腺素水平。结果①临床月经失调和不育患者在系列病例中甲功异常发生率为13．4％;②甲功正常与甲功异常的月经分布情况无统计学差异（P=0．107）。但甲功异常者发生月经失调率是甲功正常者的1．49倍;③不同甲状腺功能状态下的月经分布情况均无统计学差异（P〉0．05）。但甲亢者发生月经失调率是甲功正常者的2．31倍。亚甲亢者是甲功正常的1．40倍。亚甲减者是甲功正常的1．27倍。甲减者发生月经失调率最高,是甲功正常的3．31倍;④甲亢与甲功正常者相比,月经过少发生率有统计学差异（P=0．025）。亚甲减者发生子宫异常出血率和月经稀发率分别是甲功正常者的1．36倍和1．34倍;甲减者发生闭经率最高,是甲功正常者的5．96倍;亚甲亢和甲亢发生月经过少率均最高,分别是甲功正常者的3．42倍和10．3倍;⑤各类与甲功异常类型联系最密切的月经失调患者的促甲状腺激素、游离三碘甲状腺氨酸与游离甲状腺素水平均有统计学差异（P〈0．001）。结论甲状腺功能低落或亢进均有可能发生月经失调。甲减合并的月经失调类型总体偏于月经稀发和闭经。亚甲减与合并子宫异常出血和月经稀发的发生都较密切。甲亢和亚甲亢的月经失调类型均以月经过少为主。     

高危人群人工流产后立即高效避孕的临床观察

目的探讨高危人群人工流产术后立即放置宫内节育器(intrauterine device,IUD)或口服复方短效避孕药,对人工流产后出血、感染、月经恢复、宫腔粘连以及再次意外妊娠的影响。方法将要求终止早孕的重复(≥3次)或高危人工流产者400例分为两组,每组200例。观察组人工流产术后立即放置圆形含铜含吲哚美辛IUD,对照组人工流产术后立即口服屈螺酮炔雌醇片避孕。结果两组术后出血量、出血时间、术后感染情况比较差异无统计学意义(P0.05),而两组术后月经恢复,闭经、痛经、宫腔粘连,术后12个月内意外妊娠的发生情况比较差异有统计学意义(P0.05)。结论高危人群人工流产后立即采取高效避孕措施是安全、可靠、有效的。IUD在高效避孕的同时还有助于术后月经恢复,减少闭经痛经发生,预防宫腔粘连,降低术后12个月内再次意外妊娠的发生。对于短期无生育要求(指2年内无生育计划)者,建议人工流产术后立即放置IUD。     

Bulimia nervosa following psychological and multiple child abuse: support for the self-medication hypothesis in a population-based cohort study

OBJECTIVE: To unravel the complex role of child abuse as a risk factor for bulima nervosa (BN), from the perspective of the self-medication hypothesis which asserts that in abused BN cases binge eating is primarily a way of coping with the anxiety or mood disorders that stem from the abuse. METHOD: In a population-based study (N = 1,987) DSM-III-R diagnoses were assessed with the CIDI. Differences in exposure rates to child abuse between BN cases versus healthy, psychiatric, substance use, and dual diagnosis controls were employed to test the self-medication hypothesis. RESULTS: A history of psychological or multiple abuse was found to be a specific risk factor for dual diagnosis disorder (cases with psychiatric and substance use disorders) and for BN. Nearly all BN cases that experienced multiple or psychological child abuse, showed such comorbid anxiety or mood disorders. DISCUSSION: We found tentative support for the self-medication hypothesis.     

The female athlete triad

Regular exercise brings health benefits, but for some young women it can also bring disordered eating, amenorrhea and osteoporosis. The ‘female athlete triad’ consists of three separate, but interrelated medical entities: (i) disordered eating; (ii) amenorrhea (or absence of menses), and; (iii) premature osteoporosis (altered bone mineral density). Although coaches, athletes, parents, and to some extent team physicians, have been aware of these problems for some time, it is only relatively recently that concerns about short- and long-term health consequences have been voiced in the medical literature. Prevention of the Triad disorders starts with awareness and sensitivity to the pertinent issues. We now know that concerns about weight and dieting emerge in children between the ages of 9 to 11. Athletes and coaches must be thoroughly educated on nutrition and training principles, the development and maintenance of normal menstrual cycles, and the prevention of osteoporosis. By evaluating the female athlete triad, amenorrhea, medical complications, signs and symptoms, key signs at physical examination, and the management and prevention of the triad disorders, this article offers an important review of the female athlete triad.