Harrison's Internal Medicine Chapter 51. Menstrual Disorders and Pelvic Pain
Menstrual Disorders and Pelvic Pain: Introduction
Menstrual dysfunction can signal an underlying abnormality that may have long-term health consequences. Although frequent or prolonged bleeding usually prompts a woman to seek medical attention, infrequent or absent bleeding may seem less troubling, and the patient may not bring it to the attention of the physician. Thus, a focused menstrual history is a critical part of every female patient encounter.
Algorithm for evaluation of amenorrhea. β-hCG, human chorionic gonadotropin; PRL, prolactin; FSH, follicle-stimulating hormone; TSH, thyroidstimulating hormone.
Hypogonadotropic Hypogonadism Low estrogen levels in combination with normal or low levels of LH and FSH are seen with anatomic, genetic, or functional abnormalities that interfere with hypothalamic GnRH secretion or normal pituitary responsiveness to GnRH. Although relatively uncommon, tumors and infiltrative diseases should be considered in the differential diagnosis of hypogonadotropic hypogonadism (Chap. 333).
Role of the hypothalamic-pituitary-gonadal axis in the etiology of amenorrhea. Gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus stimulates follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secretion from the pituitary to induce ovarian folliculogenesis and steroidogenesis. Ovarian secretion of estradiol and progesterone controls the shedding of the endometrium, resulting in menses and, in combination with the inhibins, provides feedback regulation of the hypothalamus and pituitary to control secretion of FSH and LH.
Polycystic Ovarian Syndrome: Treatment The major abnormality in patients with PCOS is the failure of regular, predictable ovulation. Thus, these patients are at risk for the development of dysfunctional bleeding and endometrial hyperplasia associated with unopposed estrogen exposure. Endometrial protection can be achieved with the use of oral contraceptives or progestins (medroxyprogesterone acetate, 5–10 mg, or prometrium, 200 mg daily for 10–14 days of each month).
Acute Pelvic Pain: Treatment Treatment of acute pelvic pain depends on the suspected etiology but may require surgical or gynecologic intervention. Conservative management is an important consideration for ovarian cysts, if torsion is not suspected, to avoid unnecessary pelvic surgery and the subsequent risk of infertility due to adhesions. The majority of unruptured ectopic pregnancies are now treated with methotrexate, which is effective in 84–96% of cases. However, surgical treatment may be required.
The purpose of this book is to consider the woman and her health needs in her
position in her life cycle, her family, and society. Women have historically
been ‘‘the other’’ in medical care. Sigmund Freud and Erik Erikson considered
women’s development to be deviant from the normal, which was men’s.
Although the Greeks Hippocrates and Soranus wrote about women’s medical
needs, women’s health concerns have either been considered abnormal, or,
traditionally, been condensed to their gynecological functions and disorders,
perhaps because these were their only valued functions....
Refusal to maintain body weight at or above a minimally normal weight for age and height. (This includes a failure to achieve weight gain expected during a period of growth leading to an abnormally low body weight.)
Intense fear of weight gain or becoming fat.
Distortion of body image (e.g., feeling fat despite an objectively low weight or minimizing the seriousness of low weight).
Amenorrhea. (This criterion is met if menstrual periods occur only following hormone—e.g., estrogen—administration.
Menstrual dysfunction can signal an underlying abnormality that may have longterm health consequences. Although frequent or prolonged bleeding usually prompts a woman to seek medical attention, infrequent or absent bleeding may seem less troubling, and the patient may not bring it to the attention of the physician. Thus, a focused menstrual history is a critical part of every female patient encounter. Pelvic pain is a common complaint that may relate to an abnormality of the reproductive organs but may also be of gastrointestinal, urinary tract, or musculoskeletal origin.
Disorders of tie menstrual cycle are one of tie mosi common reasons lor women to attend their general practitioner aid, subsequently, a gynaecologist. Although rarely life threatening, menstrual disorders lead to major social and occupational disruption, and can also affect psychological well-being.
Patients aﬀected by bleeding disorders present a
wide spectrum of clinical symptoms that vary from a mild or
moderate bleeding tendency to signiﬁcant episodes. Women
with inherited bleeding disorders are particularly disadvantaged
since, in addition to suﬀering from general bleeding symptoms,
they are also at risk of bleeding complications from regular
haemostatic challenges during menstruation, pregnancy and
It has been documented, for example, that high maternal pre-pregnancy weight and excessive
weight gain during pregnancy are often associated with adverse pregnancy outcomes,
including greater risks of gestational diabetes, childbirth complications, caesarean sections,
hypertension and pre-eclampsia, and post-partum obesity. Women with severe (morbid)
obesity are more likely to experience even poorer outcomes such as stillbirths or neonatal
The rhizome of Angelica sinensis (Oliv.) Diels (Umbelliferae) is one of the most commonly used traditional drugs in China, indicated against anemia, menstrual disorders, amenorroehea and rheumatism. From the ethyl acetate extract of the roots of A. sinensis a stilbene, ferulic acid, coniferylferulate and decorticate have been isolated. Their structures were identified by MS and NMR spectroscopic methods.
Estrogen (ES-truh-jin): A type of hormone made by
the body that helps develop and maintain female sex
characteristics and the growth of long bones. Estrogens
can also be made in the laboratory. They may be used
as a type of birth control and to treat symptoms of
menopause, menstrual disorders, osteoporosis, and
Fallopian tube (fuh-LOH-pee-in): A slender tube
through which eggs pass from an ovary to the uterus.
In the female reproductive tract, there is one ovary and
one fallopian tube on each side of the uterus.