Reproductive and Sexual Health Handbook

A ‘normal’ menstrual cycle (Figure 7.1) is associated with a monthly bleed (every 21 to 35 days) with duration of seven days or less. A blood loss of 80 mls or less, per month, is regarded as being in the normal range.

A regular menstrual cycle depends on the presence of a coordinated reproductive hormone system, including the hypothalamus, anterior pituitary gland and ovaries, as well as normal uterine and vaginal anatomy. The menstrual cycle is ‘switched on’ at puberty when the hypothalamus secretes gonadotrophin-releasing hormone (GnRH). Pulses of this hormone cause the release of follicle-stimulating hormone (FSH) from the anterior pituitary. FSH in turn stimulates the growth of a cohort of ovarian follicles. The granulosa cells of the ovarian follicles produce increased amounts of the hormone oestradiol, which in turn trigger a surge of luteinising hormone (LH) causing the dominant follicle to ovulate.

As a result of stimulation by oestradiol, the endometrium thickens in preparation for implantation of an embryo should fertilisation and pregnancy occurs. The dominant follicle resolves to become the corpus luteum, which then produces the hormone progesterone as well as oestradiol. If a pregnancy does not eventuate, the corpus luteum ceases production of hormones. This causes the breakdown

Menstrual abnormalities include irregular or absent periods, heavy or prolonged menstrual loss (International Federation of Gynecology and Obstetrics (FIGO) definitions), inter-menstrual or post coital bleeding, dysmenorrhoea, and premenstrual disorders. Postmenopausal bleeding is also included in this chapter, see here.

Abnormal uterine bleeding includes:

heavy menstrual bleeding (HMB) (previously called menorrhagia) intermenstrual bleeding (IMB) post coital bleeding (PCB)(13-22) postmenopausal bleeding

Reference is made in this chapter to peri-menopausal bleeding and to pregnancy-related bleeding. Further information can be found in Chapter 11: Menopause and Chapter 9: Preconception Care and Pregnancy.

The investigation and management has been assisted by the development of The International Federation of Gynecology and Obstetrics (FIGO) classification system for abnormal uterine bleeding, which stratifies the causes of abnormal uterine bleeding into nine categories arranged according to the acronym PALM-COEIN encompassing both structural and non-structural causes.

FIGO classification system for AUB

The classification system is stratified into nine basic categories that are arranged according to the acronym PALM-COEIN:⁽¹⁴⁾

PALM-COEIN is usually applied after cervical causes have been excluded by history and vaginal and speculum examination.

Structural lesions

Polyp (AUB-P) Adenomyosis (AUB-A) Leiomyoma (fibroids) (AUB-L) Malignancy and hyperplasia (AUB-M)

Non-structural conditions

Coagulopathy (AUB-C) Ovulatory Disorders (AUB-O) Endometrium (AUB-E) Iatrogenic (AUB-I) Not Otherwise Classified (AUB-N)

 

Premenstrual syndrome covers a wide range of psychological symptoms such as anxiety, depression, mood swings and loss of confidence.⁽³⁵⁾ There are also common somatic symptoms like mastalgia and bloating.^{(33)(35)(36)(37)(38)(39)(40)(41)}

It is estimated that 40 per cent of women experience PMS symptoms and 5-8 per cent of these suffer severe PMS.⁽³⁵⁾ In premenstrual syndrome there is a clear relationship between the luteal phase of the menstrual cycle and the development of symptoms. Symptoms must be present during the luteal phase of the cycle, decline with menses which is then followed by a symptom free week.⁽³⁵⁾ It is the timing, rather than the range of symptoms, which supports the diagnosis of PMS, together with demonstration that these symptoms cause significant impairment of the individual’s daily functioning.⁽⁴²⁾ Exclude symptoms due to other psychiatric, gynaecological or medical illness.

Symptoms of premenstrual syndrome usually start to be problematic in the adolescent years and decline in the perimenopausal period. They are usually of greatest severity when a woman is in her 20s to mid-30s, but women most likely to

Requests to delay or skip a menstrual period because of an important event are common. Ideally there is sufficient time to be able to advise at least 3 weeks of a combined hormonal contraceptive method (a pill or vaginal ring) for those who are medically eligible following which the hormone-free break can be skipped in order to avert a withdrawal bleed. Alternatively, 1 tablet norethisterone 5mg (Primolut N) 2 to 3 times daily for up to 10 -14 days, beginning about 3 days before the expected menstruation can be used.  Bleeding will occur 2 – 3 days after having stopped medication. Note that due to the partial conversion of norethisterone to ethinyloestradiol, administration of Primolut N is expected to result in similar pharmacological effects as seen with COCs including an elevated risk of venous thromboembolism and should therefore not be used in women with pre-existing VTE risk factors.

Menstrual disorders are common in adolescence. Periods can be heavy, irregular or painful for the initial years following menarche. Serious pathology is rare.46 However menstrual disorders can have a significant impact on adolescents’ quality of life and result in school absences.⁽⁵¹⁾

Due to immaturity of the hypothalamic pituitary ovarian (HPO) axis in the first two years after menarche more than half of the menstrual cycles are anovulatory. With maturation of the HPO axis the cycles become regular. Dysfunction of the HPO axis and Müllerian anomalies may also be diagnosed in adolescents, these may present with delayed puberty and amenorrhoea.

Anovulatory cycles are often irregular and prolonged, which may result in anaemia.⁽⁵⁰⁾ Anovulatory cycles are typically not painful however infrequent periods and their associated heavier blood loss may result in dysmenorrhoea. With regular ovulatory cycles the periods often become painful due to the increased production of prostaglandins.⁽⁵⁰⁾

Congenital anomalies of the female reproductive tract include a wide range of deviations from normal anatomy and are rare.^{(54, 55)} They may present early at birth, with abnormalities of the external genital tract urogenital sinus, cloaca, or ambiguous genitalia, or later at adolescence, presenting with amenorrhoea, dysmenorrhoea, inability to insert a tampon or have sexual intercourse, or reproductive failure.⁽⁵⁴⁾

Later presentations are typical of abnormalities of the Müllerian tract. Müllerian anomalies occur in approximately 7 per cent of girls,⁽⁵⁶⁾ and result from failure of fusion or canalisation of the müllerian tract. When categorizing causes of congenital abnormalities of the genital tract, it is best to consider the causes as obstructive or non-obstructive.

Family Planning NSW fact sheet:

Menstrual cycle and period problems

National Centre for Gynaecological Cancers resource:

Abnormal vaginal bleeding in premenopausal and perimenopausal women, a diagnostic guide for general practitioners and gynaecologists 

The Jean Hailes Foundation resources:

Endometriosis and Polycystic Ovary Syndrome 

Endometriosis.org

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