Causes of Menstrual Abnormalities

Introduction
Terminology
Patterns of Bleeding
Causes of Menstrual Abnormailities
Diagnosis
Treatment
Myths
Summary

It is important to understand that abnormalities of menstruation are a symptom, not a disease. If at all possible, an underlying cause should be searched for and treatment should be directed at the cause.

When a woman has abnormal menstrual cycles, the cause can lie either within the uterus, within the ovary, within the hypothalamic pituitary system, or because of some other illness or hormonal disturbance. Androgen (male hormone) disorders are very common in women with a life-long history of irregular periods. This is covered in another pamphlet and will be given to you if appropriate.

The most common cause of irregular menstrual periods is the failure of ovulation to occur - either on a regular basis in which case the woman has completely irregular or on a temporary basis which may only disrupt the cycle for a short time. Organic causes within the uterus are usually fairly easy to diagnose using a combination of SONOHYSTEROGRAPHY and Hysteroscopy. Treatment then depends on what problem is found.

Even though failure of ovulation is the cause of DUB in most women, the ovary itself is rarely the primary offending organ. The ovary is not working properly to produce an egg each month either because it is not being properly instructed to do so by the pituitary hormones or because other problems are interfering with the ovary's ability to respond to the controlling pituitary hormones. PolyCystic Ovary Syndrome (PCOS), the most common endocrine disorder in women of reproductive age, is a classic example of this type of problem.

The one major exception is the presence of any persistent cyst or tumor (even benign) within the ovary. Any "foreign object" within the ovary will disrupt normal ovarian function and may lead to irregular bleeding.

One of the most common causes of DUB and anovulation in women is the increased production of androgen - male hormone. All women produce some androgen as all men produce some estrogen. However, when a woman produces excessive amounts of androgen, the ability of the ovary to respond to its controlling hormones is impaired and the ovary either ovulates abnormally or fails to ovulate at all.

Women who produce excess amounts of androgen are usually easy to recognize. They are often overweight and almost always have either acne or facial hair or both.

Women who have such a syndrome of irregular menstrual periods (or no menstrual periods at all) in association with obesity and facial hair and/or acne have been given several terms including Stein-Leventhal Syndrome and Polycystic Ovary Syndrome (PCOS) . I do not like these terms, particularly the latter, because they are inaccurate and because they convey the impression that the problem is mainly ovarian whereas in reality, the problem involves the pituitary, the adrenal, the ovary, and your metabolic "system" as well. Nonetheless, PCOS is the term everyone uses and as bad as it may be, we are stuck with it.

Newer information indicates that PCOS is really a total body disorder involving not only abnormalities in the ovary and adrenal but in the pancreas and insulin secretion as well. PCOS usually begins at puberty. If a teenage girl begins to develop symptoms of PCOS, prompt diagnosis and treatment may prevent the full-blown syndrome from developing. Unfortunately, many of these girls are simply put on oral contraceptive pills to "regulate" their cycle. This is does nothing to address the underlying cause and only delays proper diagnosis and treatment.

Another common cause of menstrual irregularity is a major change in body weight. Women who lose a great deal of weight for whatever reason will frequently develop some abnormality of menstruation. It is well established that the ratio between your body fat to lean body mass (muscles, ligaments, bones, etc.) is a major regulator of menstrual function. Women who maintain a very low ratio frequently stop menstruating. This is typically seen in women athletes, particularly marathon runners, and it is extremely common in dancers. For instance, the term "ballerina amenorrhea" has been coined because of the frequency with which this problem occurs in these women.

Women who are overweight commonly have irregular periods and these women commonly produce increased amounts of androgen solely as a function of their body weight. They are also producing increased amounts of estrogen. This occurs in the fat where androgen is converted to estrogen.

Although true anorexia nervosa is a fairly uncommon problem, eating disorders in teenage girls is not rare. In an attempt to control their weight, or as a result of various emotional stresses, many teenage girls will become anorexic or they may resort to purging or they may become bulimic. Any of these problems can disrupt their menstrual cycle.

One of the most common causes of menstrual irregularity is emotional stress. Usually the precipitating factor is easily recognized and unless the problem is significant, no specific therapy of menstrual disturbance is necessary. It has been often stated that a woman's menstrual cycle mirrors her emotions and my clinical experience has more than justified this conclusion.

Further complicating the problem of the woman who is under emotional stress is the fact that, when they either see their family physician or sometimes a psychiatrist, they will be frequently placed on Prozac or drugs similar to Prozac. Any of the "psychiatric" drugs, but especially anti-depressants, may cause elevations in the hormone prolactin.

The "major tranquilizers" - drugs that are used to treat serious mental disturbances - very frequently cause an elevated prolactin level. Drugs of this category include Thorazine, Haldol and other similar medications. Women on these drugs frequently stop menstruating completely.

When a woman is on such a drug and is found to have an elevated prolactin, the question then becomes whether it was the emotional stress that caused her menstrual irregularity or whether it was a secondary effect of the medication that was being used to treat her emotional distress.

While most people are familiar with syndromes of anorexia nervosa and other situations in which severe emotional stress and/or weight loss produce complete amenorrhea, many people are not aware that abnormalities in the menstrual cycle other than amenorrhea may also be due to emotional factors.

Another fairly common cause of menstrual irregularity is an elevation in the serum Prolactin- even in women not taking a psychiatric drug. Prolactin is a hormone produced by the pituitary and it is well known that it is necessary for breast development during pregnancy to permit breast feeding. No one yet knows what Prolactin does in non-pregnant women or in men. What is known, however, is that elevation in the Prolactin level will create menstrual abnormalities.

In some women, the elevated Prolactin is due to a small tumor of the pituitary gland. At one time, it was feared that most women with an elevated Prolactin had one of the these small tumors and it was further feared that many women would require surgery to remove them.

We now recognize that while elevated Prolactin levels are not uncommon, in the majority of instances, a tumor does not appear to be present and even when the tumor is present, surgical therapy is not necessary. The elevated Prolactin can be easily controlled with medication and even when there is a tumor present, the medication will often, at the very least, prevent the tumor from enlarging and in many instances will actually make it shrink.

Thyroid disease has long been popularly mentioned as a cause of menstrual abnormality. In fact, at least in my experience (which is rather extensive), thyroid disease is a very uncommon cause of menstrual abnormalities and 99% of women that I treat with DUB have absolutely nothing wrong with their thyroid at all.

With modern laboratory tests, it is very easy to determine with a high degree of accuracy whether or not a woman has an abnormality of her thyroid. If she has an abnormality of her thyroid function, treatment is usually simple and highly effective. If a woman does not have an abnormality of her thyroid gland, there is no justification for the use of thyroid hormone therapy.

There are many other causes of menstrual abnormalities which are beyond the scope of this discussion but the ones I have mentioned here are the most common and most important ones.