| History: The individual may report absence of or changes in the menstrual cycle and related symptoms. A thorough history must be obtained, including pubertal development, age at menarche (onset of menses), typical menstrual cycle (length, flow, number of days between menses); past and current medical conditions (especially chronic illnesses such as Crohn’s disease); any symptoms suggesting CNS disease (visual changes, headaches); history of bleeding disorders (both personal and family); dietary history (including weight loss and exercise); medications including contraception and use of hormones; history of drug or alcohol use; sexual activity; history of acne or hirsutism; family history (pubertal). A history of trauma and surgery should also be obtained.
Dysmenorrhea is characterized by crampy, labor-like pains in the lower abdomen that usually begins just prior to or at the start of the menstrual period. Pain may come and go in waves. Individuals may also report nausea, vomiting, and a dull pain in the lower back. In 10% of women, dysmenorrhea is painful enough to be incapacitating, or to interfere with work or leisure activities (Calis). In primary dysmenorrhea, cramps begin at menarche (the first menstrual period). Secondary dysmenorrhea typically begins after a few years of painless periods. In secondary dysmenorrhea, pain begins several days before and lasts throughout the menstrual period. Dysmenorrhea may be preceded by premenstrual syndrome (bloating, irritability, and depression).
A woman with menorrhagia will typically report a large amount of blood loss during her menses. The average blood loss during a menstrual period is about 2 fluid oz (60 mL); women with menorrhagia may lose 3 oz (90 mL) or more. Although this may sound like a small amount, it can lead to severe anemia.
With metrorrhagia, a woman will complain of bleeding during the interval between periods. Physical exam: Physical examination includes vital signs, height, weight, Tanner stage (a system for categorizing sexual development), general appearance (individuals with some congenital disorders may have a webbed neck or be unusually short), palpation of the thyroid and examination for other evidence of thyroid disease, examination of the breasts for galactorrhea (production of a milk-like substance), examination of the eyes, a thorough neurologic exam, evidence of elevated androgen levels (a male hormone that can cause acne or excessive hair growth [hirsutism] in women).
A pelvic exam is usually performed to determine if a uterus is present (absence of uterus indicates androgen insensitivity syndrome or agenesis) and to exclude pregnancy. Cervical findings may include effects of estrogen seen on the vaginal mucosa, mucus secretion, or lack of mucus and a dry, pale vagina suggesting ovarian dysfunction.
For women with dysmenorrhea, a bimanual pelvic exam can determine if there is uterine tenderness, enlarged ovaries, or fibroid tumors. Tests: The type of menstrual abnormality will determine the need for tests. Blood tests may include a complete blood count to look for anemia or infection, chemistries and endocrine tests to assess for chronic disease, measurement of thyroid and reproductive hormones, and a pregnancy test.
Imaging studies may include transabdominal or transvaginal ultrasound (sonography) of the abdomen and pelvis to identify masses such as ovarian tumors or fibroids; ultrasound is also helpful in assessing uterine size and shape. CT scan or magnetic resonance imaging (MRI) can detect pituitary tumors in the brain, while abdominal or pelvic CT or MRI can show tumors of the adrenal glands. Diagnostic tests for dysmenorrhea, menorrhagia, and metrorrhagia may include pregnancy test, Pap smear, or urine and cervical cultures. An endometrial biopsy, ultrasound, or laparoscopy may be considered. |