Menstruation, or shedding of the endometrium, is part of a 28-day cycle, and it’s a normal physiologic process as the Physician Assistant Exam will expect you to know. Menarche is the name for the first menstrual period, and it usually takes place between the ages of 10 and 16, with the median age being 12 or 13 years.
The PANCE/PANRE may ask about the range of starting ages as well as about abnormalities in a woman’s menstrual cycle.
Missing periods: Consider primary and secondary causes of amenorrhea
Amenorrhea is the absence of menstrual periods in a woman of reproductive age. Amenorrhea can have primary and secondary causes. Primary amenorrhea is the failure of menses to start by the age of 16 years in the presence of normal growth and secondary sexual characteristics.
If by age 13 menses has not started and the onset of puberty is absent, a workup for primary amenorrhea should start. Primary amenorrhea can be due to problems with the organs themselves — problems with the uterus (congenital absence of one) or the ovaries. Alternatively, it can be due to a problem with the hypothalamus-pituitary axis.
Secondary amenorrhea is defined as the early cessation of menses. In this case, the body or a particular organ isn’t making the necessary hormones for a woman to have menstrual cycles. Some experts diagnose secondary amenorrhea only after a woman hasn’t had a menstrual cycle for 6 months or more; others believe that 90 days marks the minimum time requirement.
Common causes of amenorrhea include hypothyroidism, prolactinoma, and polycystic ovarian syndrome (PCOS). Dramatic changes in weight, either significant gain or loss, can also be causes of amenorrhea. Some marathon runners are so calorically deprived that they develop a secondary amenorrhea. Eating disorders, such as anorexia or bulimia, can also be causes.
On clinical presentation, you want to look for physical changes. Does she have more facial hair than before? Hirsutism may be a sign of polycystic ovarian syndrome or Cushing’s. Does she have any nipple discharge? You see discharge with pituitary tumors. If her weight has changed, does she have an underlying eating disorder, has she had recent surgery, or is a malabsorption syndrome causing changes in weight?
The workup for amenorrhea includes the measurement of various hormone levels, including TSH, FSH, LH, and prolactin. Don’t forget the good old β-hCG, because you don’t want to miss a pregnancy, which is the most common cause of secondary amenorrhea. The treatment depends on investigation of the underlying problem.
Painful periods: Diagnose dysmenorrhea by process of elimination
Dysmenorrhea is defined as a painful menstruation. Most commonly, this occurs when women first start menstruating and again in women in their late 30s and early 40s. When a woman has dysmenorrhea, think of two basic processes: endometriosis and chronic pelvic pain, which you usually see in someone with a history of pelvic inflammatory disease (PID), although this condition can have other etiologies.
The workup for dysmenorrhea involves exclusion of other disorders, such as an STD or cervicitis. Women sometimes need pelvic ultrasounds and surgical interventions for you to exclude other causes. The treatment includes evaluating the underlying cause as well as symptomatic pain relief, which means the use of nonsteroidals and analgesics as needed.
Premenstrual syndrome
Premenstrual syndrome (PMS) is a constellation of various symptoms, both physical and psychological, that are connected with the menstrual cycle. These symptoms, which can be debilitating, occur before or during menses.
Symptoms of PMS include labile moods, irritability, gastrointestinal upset, insomnia, anorexia or a ravenous appetite, and myalgias. The woman may have dysmenorrhea as well.
The cause of PMS isn’t known. Nutrient deficiencies, in addition to hormonal alterations during the menstrual cycle, may play a role. The treatment includes lifestyle changes, such as beginning an exercise regimen (to increase endorphins), as well adopting more of an anti-inflammatory diet in case the condition is triggered by a specific food group.
Avoiding caffeine, correcting nutrient deficiencies, and getting an adequate ingestion of vitamins and minerals may help. As always, anti-inflammatories and analgesics can be important for symptomatic management.
You’re evaluating a 25-year-old woman who states that she has regular menstrual periods. However, they’re associated with heavy flow and usually last about 6 to 8 days without significant pain. Which one of the following defines this young woman’s medical condition?
(A) Amenorrhea
(B) Dysmenorrhea
(C) Menorrhagia
(D) Oligomenorrhea
(E) Endometrial cancer
The correct answer is Choice (C). Menorrhagia is defined as periods that occur regularly and are on schedule but have heavy flows and last a little longer than a normal menses. Amenorrhea means the absence of a menses. Dysmenorrhea refers to painful menses. Oligomenorrhea is menses in a cycle that’s greater than 30 days.
When you’re evaluating a question concerning vaginal bleeding, you should assess cancer risk. You see endometrial cancer, Choice (E), in an older woman, usually postmenopausal, who presents with vaginal bleeding. The woman in this example question has no known risk factors for endometrial cancer.