Alterations in the menstrual cycle can be considered as a symptom caused by more complex pathologies: how to recognize them and behave
Menstrual cyclicality is the expression of a fine balance characterized by the cyclical alternation of hormones produced by the ovaries, in particular estrogen and progesterone, under the stimulation of other hormones, gonadotropins, produced in the hypothalamus and pituitary gland. This hormonal production mechanism is quite complex and induces, as a final result, some functional changes in the target tissues of the female reproductive system (uterus, endometrium, vagina), the most evident of which is menstruation.
Correct menstrual cyclicality therefore requires the integrity of:
Many pathological conditions, endocrinological and otherwise, involving one or more of these districts can cause an alteration of the menstrual cycle.
- Definition of impaired menstrual cyclicality
- Causes of impaired menstrual cyclicality
- Diagnostic framework
Definition of impaired menstrual cyclicality
By definition, the menstrual cycle begins with the first day of blood loss and ends with the day before the next menstruation begins. The median duration of a cycle is approximately 28 days during the intermediate phase of a woman's reproductive period; however, the menstrual cycle exhibits extreme variability from woman to woman, also depending on the various periods of reproductive life.
Changes in the menstrual cycle can be classified into:
- quantitative: characterized by a reduction (hypomenorrhea) or increase (hypermenorrhea, menorrhagia) in menstrual flow.
In most cases, in association with hypomenorrhea and hypermenorrhea, there are no alterations in the functionality and regulation of the menstrual cycle. However, hypermenorrhea is worthy of particular attention as it can expose the woman to anemia. Organic or endocrinological causes are rarely identified and in most cases it is due to alterations in the local metabolism of prostaglandins, the mediators of the onset and arrest of menstrual bleeding.
- qualitative: characterized by alterations of the menstrual periodicity, that is an elongation (oligomenorrhea) or shortening (polymenorrhea) of the intermenstrual period. If there is a prolonged absence of menstrual flows for more than 3 months, this is defined
In addition, metrorrhagia is defined as abundant bleeding that occurs intermenstrically, that is, outside the menstrual phase. Finally, the term dysmenorrhea defines a menstrual flow associated with painful symptoms.
Causes of impaired menstrual cyclicality
The alterations of the menstrual cycle listed above are to be considered as a symptom, caused by more complex pathologies that must be correctly framed and diagnosed in order to be adequately treated.
Simplifying, cycle alterations, especially qualitative ones, can recognize:
- a central cause due to hypothalamic and / or pituitary problems or
- a peripheral cause due to pathologies of the ovary.
The most frequent central endocrinological causes are:
- organic causes: benign or malignant tumors in the hypothalamus-pituitary region with or without hyperprolactinemia, inflammatory or autoimmune diseases of the hypothalamus-pituitary region
- functional causes: psycho-physical stress, intense physical exercise, weight loss and malnutrition, psychic (eating disorders such as anorexia nervosa and bulimia)
The most frequent peripheral endocrinological causes are:
- polycystic ovary syndrome: a frequent morbid condition, which affects more than 10% of women of reproductive age, characterized by considerable clinical and biochemical variability, but whose fundamental elements are: 1) the absence of regular ovulation; 2) the presence of clinical hyperandrogenism (hirsutism, acne, alopecia) or biochemical, documented with increased levels of circulating androgens; 3) the ultrasound appearance of a micropolicistic ovary.
- hyperandrogenisms (androgen-secreting ovarian or adrenal tumors, congenital adrenal hyperplasia)
- ovarian infections
- autoimmune pathologies of the ovary
- ovarian pathologies induced by radiotherapy and chemotherapies for the treatment of tumors
Furthermore, the presence of alterations in thyroid function, such as hypothyroidism or hyperthyroidism, and the use of chronic cortisone drugs or some drugs with a hyperprolactinemizing effect can alter the normal menstrual cycle and induce alterations in the menstrual cycle, mostly of a qualitative type. .
Finally, it should be remembered that a picture of amenorrhea or oligomenorrhea can occasionally be accompanied by some systemic diseases (hepatic, renal, cardiac insufficiency, serious infections, neoplasms, malabsorption syndromes, etc.) which with various mechanisms can interfere with the physiological functioning of the hypothalamus-pituitary-ovary axis.
The diagnostic evaluation first of all presupposes an accurate menstrual history (characteristics of the flows, any intermenstrual losses, presence of other associated symptoms) and a complete remote and immediate pathological history aimed at highlighting above all the presence of intercurrent and / or previous diseases, changes in body weight , situations of significant psycho-physical stress, use of interfering drugs.
The physical examination consists of a thorough general examination aimed both at detecting signs of other diseases not affecting the reproductive system that may cause alterations in the menstrual cycle (chronic diseases, serious systemic diseases involving vital organs such as heart, liver and kidney, etc.), and to identify symptoms and signs (hypertrichosis, hirsutism, arterial hypertension, overweight / obesity, etc.) that could lead to specific pathological pictures and in a specific gynecological examination.
Furthermore, laboratory investigations must be carried out and in particular hormonal assays and ultrasound instrumental evaluations of the uterus and ovaries.
In conclusion, a correct diagnostic framework, which often requires the multidisciplinary collaboration of endocrinologists, gynecologists and psychologists, is fundamental to be able to use the wide range of therapeutic opportunities currently available that allow the resolution of the triggering cause and the restoration of regular menstrual cyclicality. thus ensuring excellent results for patients.
In collaboration with Dr. Giovanna Motta
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Tag: Menstrual cycle Hormones