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Upon completion of the chapter, the reader will be able to:

  1. Describe the underlying etiology and pathophysiology of dysmenorrhea, amenorrhea, anovulatory bleeding, and menorrhagia and how they relate to selecting effective treatment modalities.

  2. Describe the clinical presentation of dysmenorrhea, amenorrhea, anovulatory bleeding, and menorrhagia.

  3. Recommend appropriate lifestyle and dietary modifications and pharmacotherapeutic interventions for patients with dysmenorrhea, amenorrhea, anovulatory bleeding, and menorrhagia.

  4. Identify the desired therapeutic outcomes for patients with dysmenorrhea, amenorrhea, anovulatory bleeding, and menorrhagia.

  5. Design a monitoring plan to assess the effectiveness and adverse effects of pharmacotherapy for dysmenorrhea, amenorrhea, anovulatory bleeding, and menorrhagia.




  • Image not available.Nonsteroidal anti-inflammatory drugs (NSAIDs) are the treatment of choice for dysmenorrhea due to their effect on prostaglandins. In addition to their analgesic properties, NSAIDs also inhibit prostaglandin production, decreasing uterine contractions.

  • Image not available.Intrauterine devices (IUDs) are considered therapeutic options in a variety of menstrual-related disorders. Guidelines from the American College of Obstetricians and Gynecologists states that any woman (regardless of parity), including adolescents, at low risk of sexually transmitted diseases (and thus pelvic inflammatory disease) is a good candidate for IUD use.

  • Image not available.Unrecognized pregnancy remains the most common cause of amenorrhea, and a urine pregnancy test should be one of the first steps in the evaluation of this disorder.

  • Image not available.For most conditions associated with primary and secondary amenorrhea, estrogen treatment (along with a progestin to minimize the risk of endometrial hyperplasia) is utilized.

  • Image not available.Anovulatory bleeding, also referred to as dysfunctional uterine bleeding, is secondary to the effects of unopposed estrogen and does not include bleeding owing to an anatomic lesion of the uterus.

  • Image not available.The use of metformin and thiazolidinediones for anovulatory bleeding associated with polycystic ovary syndrome is beneficial for anovulatory bleeding and fertility and also improves glucose tolerance and decreases overall cardiovascular risk.

  • Image not available.Causes of menorrhagia can be divided into systemic disorders and reproductive tract abnormalities.

  • Image not available.Intrauterine pregnancy, ectopic pregnancy, and miscarriage must be at the top of the differential diagnosis list for any woman presenting with heavy menses.

  • Image not available.The reduction in menorrhagia-related blood loss with the use of NSAIDs and oral contraceptives is directly proportional to the amount of pretreatment blood loss.


Women of reproductive age commonly experience menstrual cycle-related maladies. The disorders in this chapter are most frequently encountered and include dysmenorrhea, amenorrhea, anovulatory bleeding, and menorrhagia. The need to effectively treat these disorders stems from their impact on a reduced quality of life, negative effects on reproductive health, and/or the potential for detrimental health effects over time, notably osteoporosis with amenorrhea and cardiovascular disease with polycystic ovary disease.




Dysmenorrhea is pelvic pain, generally described as cramping, that occurs during or just prior to menstruation. Primary dysmenorrhea is pain in the setting of normal pelvic anatomy and physiology, whereas secondary dysmenorrhea is associated with underlying pelvic pathology.1


Epidemiology and Etiology


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