Menstrual disorders, amenorrhea, and dysmenorrhoea

Symptoms related to menstruation are the commonest cause of gynaecological complaints during the reproductive years, and cause more work absences than any other disorders commonly seen in women. These disturbances of menstrual bleeding and menstruation-associated pain can have major impacts on quality of life, and can lead to the development of significant symptoms due to iron deficiency and anaemia. There is a range of common and rare underlying causes of abnormal uterine bleeding, which have been well classified using the PALM-COEIN system. Investigations should be targeted at defining the underlying causes and assessing the degree of iron deficiency. Treatment depends on the underlying cause, and a range of surgical and medical approaches can be considered—improved quality of life is the key aim. Effective treatment for heavy menstrual bleeding should be accompanied by effective treatment for iron deficiency. Amenorrhoea (absence of menstruation for a specified period of time) may be due to disturbances of almost any part of the hypothalamic–pituitary–ovarian–uterine system. Investigations should focus on the interplay of reproductive hormones and exclusion of structural pathology. Treatment is aimed at managing the underlying cause, taking into account the desires of the patient in relation to pregnancy. Menstrual pain may be caused by an imbalance of prostaglandin metabolism (primary dysmenorrhoea) or by structural pathologies, such as endometriosis (secondary dysmenorrhoea). Symptoms can vary greatly and a careful history can often distinguish realistically between primary and secondary dysmenorrhoea. Treatment is often medical, although structural pathologies may require surgical excision.