Menstrual disorders and their management

The normal human menstrual cycle is characterized by cyclical vaginal bleeding lasting 4±2 days and occurring at intervals of 28±7 days. From the classic work of Hallberg et al. (Acta Obstet Gynecol Scand 1966, 45:320-351), it has been determined that the upper limit of normal menstrual blood loss is between 60 and 80 mL, and that loss greater than 80 mL should be considered abnormal. This is based on increased frequency of iron deficiency in subjects with menstrual blood loss in the range of 61 to 80 mL, which is more marked when blood loss exceeds 80 mL. In addition, in a group of healthy subjects who considered their menstruation normal and had no evidence of iron deficiency anemia, the 95th percentile of normal blood loss is 76.4 mL, which agrees with the upper normal limit of 80 mL menstrual blood loss previously described. Incidence and prevalence rates of menorrhagia are difficult to identify, but population studies in Western Europe reveal that 10% to 15% of women may have menorrhagia while 20% of the population in Asia may be affected. Menorrhagia is one of the most frequent menstrual cycle disturbances. Others include polymenorrhea (menses at intervals of less than 21 days), oligomenorrhea (menses at intervals of greater than 35 days), metrorrhagia (menses at irregular but frequent intervals), and amenorrhea (absence of menses). Ovulatory disturbances rather than Mullerian tract anomalies (eg, cervical stenosis) usually account for oligomenorrheic events, whereas both structural anomalies (eg, leiomyomata) and ovulatory disturbances frequently result in irregular or excessive vaginal bleeding. Menorrhagia is of special concern because it can be life threatening when it occurs acutely and may cause fatigue and illness when it occurs chronically. As a result, it is frequently listed as a major indication for hysterectomy. With over one million hysterectomies a year performed in North America, the accurate diagnosis of menorrhagia is quite important. Diagnosis of menorrhagia remains a problem because objective measurements of menstrual blood loss do not usually correlate with the subjective complaints of patients unless confirmed by serially declining hematocrit determinations without another known etiology for anemia being present. Several publications addressing menstrual cycle disturbances and their etiology and management appeared in 1989 and have been reviewed with interest. These publications addressed either physiology, diagnosis, or therapy of menorrhagia. It is the purpose of this presentation to discuss these important new observations. As in any investigation, it is extremely helpful to be able to look at an overview of a particular problem before studying it in detail. In this light, the recent review by Van Eijkeren et al. [1] deserves special mention as it succinctly discusses previous population, biochemical, and physiologic studies of menorrhagia, finally concluding with a brief summary of current treatment. It provides a useful foundation for discussion of the topic of menstrual cycle disturbances, particularly when combined with an earlier review on this topic written by Christiaens et al. (Obstet Gynecol Surv 1982, 37:281-302).