C h a p t e r 4 0
Disorders of the Female Genitourinary System
1039
simultaneously degenerate, or the needs of an enlarged
endometrial tissue mass may exceed the capabilities
of the functioning follicles. Estrogen and progesterone
deficiencies are associated with the absence of ovula-
tion, hence the term
anovulatory bleeding
. Because the
vasoconstriction and myometrial contractions that nor-
mally accompany menstruation are caused by proges-
terone, anovulatory bleeding seldom is accompanied by
cramps, and the flow frequently is heavy. Anovulatory
cycles are common among adolescents during the first
several years after menarche, when ovarian function
is becoming established, and among perimenopausal
women, whose ovarian function is beginning to decline.
Dysfunctional bleeding can originate as a primary
disorder of the ovaries or uterus or as a secondary
defect in ovarian function related to hypothalamic-
pituitary stimulation. The latter can be initiated by
emotional stress, marked variation in weight (i.e., sud-
den gain or loss), or nonspecific endocrine or metabolic
disturbances. Nonhormonal causes of irregular men-
strual bleeding include endometrial polyps, submuco-
sal myoma (i.e., fibroid), bleeding disorder (e.g., von
Willebrand disease, platelet dysfunction), endometrial
dysplasia, and cancer.
The treatment of dysfunctional bleeding depends
on what is identified as the probable cause. The mini-
mum evaluation should include a detailed history with
emphasis on bleeding pattern and a physical examina-
tion. A pregnancy test is important to rule out any com-
plications of pregnancy. Endocrine studies (e.g., FSH/
LH ratio, prolactin, androgen levels), ultrasonography
of the endometrium, and endometrial biopsy may be
needed for diagnosis. Nonhormonal causes generally
require surgical intervention. Dilatation of cervix and
scraping of the endometrium (D&C) can be therapeutic
as well as diagnostic. Endometrial ablation (destruction
of the basal layer of the endometrium from which the
monthly buildup generates) has become a primary treat-
ment method for abnormal uterine bleeding.
11
Various
ablation devices are available; some use heat while oth-
ers use cryotherapy. If nonhormonal problems have
been excluded and alterations in hormone levels are the
primary cause, treatment may include the use of oral
contraceptives, cyclic progesterone therapy, or long-acting progesterone injections or implants.
Amenorrhea
There are two types of amenorrhea: primary and sec-
ondary. Primary amenorrhea is the failure to menstru-
ate by 15 years of age, or by 13 years of age if failure
to menstruate is accompanied by absence of second-
ary sex characteristics.
46
Secondary amenorrhea is the
cessation of menses for at least 6 months in a woman
who has established normal menstrual cycles. Primary
amenorrhea usually is caused by gonadal dysgenesis,
congenital müllerian agenesis, testicular feminization,
or a hypothalamic-pituitary-ovarian axis disorder.
Causes of secondary amenorrhea include ovarian, pitu-
itary, or hypothalamic dysfunction; intrauterine adhe-
sions; infections (e.g., tuberculosis, syphilis); pituitary
tumors; anorexia nervosa; or strenuous physical exer-
cise, which can alter the critical body fat–to–muscle
ratio needed for menses to occur.
46
Diagnostic evaluation resembles that for dysfunc-
tional uterine bleeding, with the possible addition of
a computed tomographic scan or MRI to exclude a
pituitary tumor. Treatment is based on correcting the
underlying cause and inducing menstruation with
cyclic progesterone or combined estrogen–progesterone
regimens.
Dysmenorrhea
Dysmenorrhea
is pain or discomfort with menstrua-
tion. Although not usually a serious medical prob-
lem, it causes some degree of monthly disability for
a significant number of women. There are two forms
of dysmenorrhea: primary and secondary. Primary
dysmenorrhea is caused by the effects of excess
prostaglandin production in the endometrium.
47
Prostaglandins are potent smooth muscle stimulants
that cause intense uterine contractions. Prostaglandin
production in the uterus normally increases under the
influence of progesterone, reaching a peak at or soon
after the onset of menstruation. With onset of men-
struation, formed prostaglandins are released from
the shedding endometrium. Prostaglandins also cause
contraction of smooth muscle elsewhere in the body.
Severe dysmenorrhea may be associated with systemic
symptoms such as headache, nausea, vomiting, and
diarrhea. The pain of primary dysmenorrhea is often
diffusely located in the lower abdomen or suprapubic
area, radiating to the lower back. The pain is often
described as cramping and spasmodic, or similar to
labor pains. Secondary dysmenorrhea is menstrual
pain caused by structural abnormalities or disease
processes such as endometriosis, uterine fibroids, ade-
nomyosis, pelvic adhesions, IUDs, or PID. In women
with secondary dysmenorrhea, the pain often lasts
longer than the menstrual period; it may begin before
menstrual bleeding begins; and it may become worse
during menstruation.
Treatment for primary dysmenorrhea is directed at
symptom control.
47
Women with primary dysmenor-
rhea generally experience dramatic pain relief with the
nonsteroidal anti-inflammatory drugs (e.g., ibuprofen,
naproxen, mefenamic acid), which are prostaglandin
synthetase inhibitors. Ovulation suppression and symp-
tomatic relief of dysmenorrhea can be instituted simulta-
neously with the use of hormonal contraceptives. Relief
of secondary dysmenorrhea depends on identifying the
cause of the problem. Medical or surgical intervention
may be needed to eliminate the problem.
Premenstrual Syndrome Disorders
Premenstrual syndrome disorders are a group of physi-
cal, emotional, and behavioral changes that occur in
a regular, cyclic relationship to the luteal phase of the
menstrual cycle and that interfere with some aspect of
