Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Menstrual problems of the adolescent Richard P. Dickey To cite this article: Richard P. Dickey (1976) Menstrual problems of the adolescent, Postgraduate Medicine, 60:4, 183-187, DOI: 10.1080/00325481.1976.11714456 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714456
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 24 August 2017, At: 03:18
•
1pma annais
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
from the 60th interstate postgraduate medical assembly
• The age of men arche differs from one individual to another, as does the time required to reach reproductive maturity. The transition period may be a difficult time for the young girl involved, and the family physician or the pediatrician may be called on to interpret for both the girl and ber parents what is normal and what is. not. Problems of menstrual dysfonction are common during the first 18 months following menarche. In most instances they are short-lived or can be managed with simple medical treatment, but sorne are early manifestations of reproductive disorders which will persist throughout life. It is important for the physician to determine early which type of problem is involved, so that unnecessary treatment can be avoided and necessary treatment instituted. Events of Puberty
Pubertal changes occur at a constant rate in response · to hormonal stimulation. The usual sequence and approximate timing of changes are known (table 1), and variations can be used to predict possible problems. Estrogen-dependent changes appear at about the age of 11 years, with a range of 8 to 14 years. Fat deposition occurs in the hips and thighs, the breasts begin to develop, and the body of the girl begins to assume the mature female form. Within about four months, hair appears in the pu bic area and about six months later in the axillae; these are androgen-dependent characteristics. The beginning of breast development (the larche) and hair growth (adrenarche) precede by about a year the so-called growth spurt, which in tum occurs about 1V2 years before menarche. The timing of the onset of normal menarche is now thought to be related to weight and to height, an increase in both being necessary before menstruation can begin. Menarche occurs when the growth spurt be gins to level off, and it is estimated that the average girl will grow only about 21f2 inches more after menarche.
menstrual problems of the adolescent Richard P. Dlckey, MD Louisiana State University Medical School New Orleans
Pubertal changes occur at a constant rate and in a particular sequence; deviations are indicative of possible menstrual problems. Such problems include precocious puberty, amenorrhea, menstrual irregularity, cramps, and premenstrual tension. Of those patients with menstrual irregularity, 10% to 15% will have chronic conditions requiring lifelong treatment.
Precocious Puberty
Precocious puberty is now defined as the onset of menses before age 10. Very often it is familial. About 80% to 90% of girls affected are found to have no abnormality, while 3% to 5%
Vol. 60 • No. 4 • October 1976 • POSTGRADUATE MEDICINE
183
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
table 1. events of puberty Variable
Average age (years)
Range (years)
Breast growth
11
8-14
Growth of pubic and axillary hair
11
8-14
Growth spurt
12
9Y2·14Y2
Menarche
13Y2
10-16
From Dickey RP: Reproductive anatomy, physiology, and endocrinology. ln Esinman AW, Knox EG, Tyrer L (Editors): Seminar in Family Planning. Ed 2. Chicago, ArMerican Collage of Obstetrics and Gynecology, 1974. With permission.
have a lesion of the central nervous system, as in those with Albright's syndrome or who are mentally retarded. Of girls with early menarche, 10% to 15% have an ovarian tumor. Such a tumor may produce either estrogen or androgen; rarely it produces both. In most cases, the presence of menses and breast development without pubic and axillary hair is diagnostic of an estrogensecreting tumor. Androgen-producing tumors are uncommon and are associated with marked virilization or growth of pubic and axillary hair without breast development and usually no menses. This latter type of tumor may also occur in the adrenal gland.
Turner's syndrome. X-ray films of the long bones and epiphyses and also of the short bones of the wrist are valuable for detecting delayed bone development. If these films show a bone maturity of, say, 13'1.2 years (the average age for on set of menses) in a girl with normal secondary se x characteristics, menarche should be imminent. Absence of menarche for three years or more after the development of secondary sex characteristics may stem from an anomaly of the genital tract, such as an imperforate hymen, or from sorne failure of development of the uterus or the vagina. The presence of normal estrogen- and androgen-dependent secondary sex characteristics attests to normal functioning of the ovaries. If only estrogen-dependent characteristics are present, the patient may, in fact, be a male pseudohermaphrodite whose feminine characteristics result from a condition such as feminizing testes syndrome, in which testosterone produced by the testes is interpreted by cellular receptors as estrogen. In this syndrome the effects of androgen are completely lacking. On the other band, if only androgendependent characteristics are present, the patient may be a female pseudohermaphrodite, masculinization being caused by a tu mor, hyperplasia, or an enzyme defect of the adrenal gland.
Amenorrhea Menstrual lrregularlty
Since menarche usually occurs about 2'1.2 years after thelarche and adrenarche, a prediction of primary amenorrhea can be made earlierthan age 18, as in the case of a 16-year-old girl with no sign of breast or pubic and axillary hair development or a girl of the same age without menses in whom secondary sex characteristics began to develop at the age of Il or 12 years. Secondary sex characteristics may fail to appear because of a generalized delay in maturation due to such a pathologie state as hypothyroidism or congenital heart disease or to genetic defects such as that present in
About 10% to 15% of women have irregular menses and dysfunctional bleeding problems; usually these women also are infertile. Regular menses normally begin about 12 months after menarche, with a range of approximately 6 to 18 months. Absence of regular menstruation within 12 months after the first period is a cause for sorne worry; after 18 q~.onths the patient is known to be one of the 10% to 15% destined to have lifelong menstrual problems. Menstrual irregularity can be divided into three categories: (1) infrequent menses with
184
POSTGRADUATE MEDICINE • October 1976 • Vol. 60 • No. 4
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
hirsutism and virilization, (2) infrequent menses without hirsutism, and (3) hypermenorrhea. Infrequent menses, hirsutism, and virilization-The patient with this type of irregularity most likely has Stein-Leventhal syndrome, or what is now called the polycystic ovary syndrome, ie, ovaries unresponsive to gonadotropins and producing androgen in excessive amounts. However, there is a 15% chance that the problem is caused by mild adrenogenital syndrome, in which excess androgen is secreted by the adrenal gland, and a rare chance that a tumor is present. Evaluation should include determination of levels of 17-ketosteroid (to rule out adrenal tumor) and, if possible, of testosterone (to rule out ovarian tumor) and luteinizing hormone (LH) (characteristically elevated in polycystic ovary syndrome). A trial of clomiphene citrate (Clomid) is given initially in an attempt to regulate menstruation and establish a diagnosis of polycystic ovary syndrome. I have found that menses are regulated in about 90% of patients with this syndrome who are given clomiphene for 3 to 12 months, and that the period remains regular after therapy is discontinued. A second treatment is to place the patient on a regimen of oral contraception, whereby menses are regulated and ovarian production of abnormal amounts of androgen is halted. I feel this is one of the few instances in which use of an oral contraceptive is justified in girls who have recently begun menstruating. If there is no response to either of these regimens, the patient may be one of the 15% with mild adrenogenital syndrome and should be given a trial of adrenocorticosteroid therapy. Dexamethasone (Decadron, 0.5 mg at bedtime) has proved to be the most useful short-term treatment. Iftreatment is effective, the menstrual cycle will become normal within six to eight weeks, at which time 5 mg of prednisone can be substituted for the dexamethasone. Therapy may be discontinued
after one year with a good chance that normal cycles will continue. Infrequent menses without hirsutism-A patient with this type of menstrual irregularity sometimes also has galactorrhea. The syndrome is usually caused by hypothalamic insufficiency and more rarely by pituitary insufficiency or pituitary adenoma. Extensive evaluation is required, with attention focused on thyroid function and on fas ting blood sugar level if diabetes mellitus is found in the family his tory. (However, about 50% of patients who become diabetic have no family history of this disease.) A complete white blood cell count and radioimmunoassays of serum LH and follicle-stimulating hormone (FSH) should be done to check for premature ovarian failure and for pituitary adenoma. Skull x-ray films should be made, again to rule out pituitary tumor. If possible, serum prolactin levels should be measured. If menses cease entirely (or never began), a chromosomal analysis should be obtained. If the workup fails to disclose any organic cause for menstrual irregularity, watchful waiting is the best policy. The use of oral contraception is not recommended in these patients. Hypermenorrhea-Excessive bleeding is the most frequent complaint associated with irregular menstruation. The cause is usually hypothalamic immaturity: The hypothalamus and the pituitary do not yet respond normally to feedback of ovarian estrogen and thus estrogen secretion is irregular . ..,..
Vol. 60 • No. 4 • October 1976 • POSTGRADUATE MEDICINE
185
table 2. organic causes of hypermenorrhea System le Blood dyscrasia Diabetes Thyroid disorders
Reproductive organs Endometrial or cervical polyps Vaginal or cervical neoplasm Abnormal pregnancy
Cramps are a common problem associated with menstruation. They usually do not begin until regular ovulation begins, 10 to 14 months after menarche. Their appearance signais that progesterone is being produced by the corpus luteum in the luteal phase of the cycle.
It is now believed that prostaglandins are the primary cause of menstrual cramps. Prostaglandins are produced in the endometrium and myometrium, and their release is thought to cause nausea, cramping, and pain. These typical menstrual symptoms have been produced when prostaglandins have been administered in connection with other medical problems. Rarely, blood clots or cervical stenosis will be found as the causative agent. A pelvic or rectal examination should be done to ascertain that the uterus and ovaries are normal. If cramps result from prostaglandin production, aspirin, which is a prostaglandin antagonist, will be useful as therapy and may also reduce menstrual blood loss. Not surprisingly, aspirin is a major component of most patent medicines for dysmenorrhea. (Most old-time ''female'' patent medicines contained ethyl alcohol; Lydia Pinkhams, before prohibition, was 40 proof. A glass of wine is also effective. Ethyl alcohol tums off the oxytocin-producing centers in the pituitary.) A second treatment for menstrual cramps is amphetamine. It is thought to act as an antagonist to prostaglandin, or possibly as an agonist to the adrenergic system, which in tum antagonizes prostaglandin. I give dextroamphetamine sulfate in a dosage of 5 mg every four to six hours for severe menstrual cramps. Progestogen is also effective when given for five to seven days before the onset of menses. Menstrual cramps are extremely rare in women using oral contraception. However, it is not necessary to give a pill for 21 days to treat a condition that only lasts three or four days. I give a pure progestogen (Micronor or Nor-Q.D., 0.35 mg) five days before the expected onset of menses (if cycles are regular) or at the first sign of premenstrual tension. The patient takes one or two tablets per day for five days. Other progestogens (Duphaston, Lo/Ovral, Norlutate, Provera) also are effective.
186
POSTGRADUATE MEDICINE • October 1976 • Vol. 60 • No. 4
Richard P. Dlckey
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
Dr. Dickey is clinical associate professor of obstetrics and gynecology, Louisiana State University Medical School, New Orleans.
Table 2 lists possible organic causes of hypermenorrhea; these conditions are seen rarely. A pelvic examination with use of a speculum is always necessary. Thyroid function studies should be done and a complete blood count made. If possible, levels of FSH and LH should be determined. Treatment for hypermenorrhea begins with a high dose of estrogen to stop the acute bleeding. I recommend conjugated estrogens (Premarin), 20 mg given intramuscularly, with the dose repeated in four hours if necessary. An intensive regimen of oral contraception is begun at the same time to suppress endometrial proliferation and to develop the blood vessels in the endometrium. I find a combination contraceptive, such as Ovulen, works weiL To effect this so-called medical curettage, two pills a day should be given for seven to ten days. Withdrawal flow will be unsatisfactory if the period of administration is shorter; longer administration is seldom necessary. In a patient who must be chronically treated, a progestogen in tablet form, such as norethindrone acetate (Norlutate), dydrogesterone (Duphaston), or medroxyprogesterone acetate (Provera), or any of the oral contraceptives containing progestogen may be given in double the normal dose for the last seven days of each cycle. Dilatation and curettage are rarely necessary. Menstrual Cramps
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
Premenstruel Tension
ihto ber adult years. If possible, Pap tests should be begun l;lt this time. The test is easily accomplished in a young girl without the use of a speculum: A cotton-tipped applicator is moistened in a saline solution and inserted through the hymen. A speculum is also not required for a pelvic examination except in cases of persistent abnormal bleeding. Oral èontraception is used sparingly in pubertal adolescents. It is never used to start menstruation in a patient with delayed menarche whose problem bas not been diagnosed. Approximately 1% to 3% of women who use oral contraception will have persistent amenorrhea on discontinuing the drug. In most cases, these are women who had irregular menses beginning in adolescence, and many of them have used oral contraception since their early teens. In dealing with menstrual problems in adolescents, wisdom and patience are prime requisites, as is also the ability to recognize normal variation and to diagnose promptly abnormal events or delays of events. •
Premenstrual tension occurs only in patients with ovulatory cycles and in patients who are taking a birth control pill with an amount of progestogen excessive for their particular physiologie makeup. It is thus thought to be due principally to sodium and water retention, caused by the cyclic drop in luteal progesterone production. Immediate treatment would appear to be use of a low-salt diet and a diuretic; both of these do work. Paradoxically, progestogen given in low doses for five tose ven days before the onset of menses also seems to prevent premenstrual tension. Comment
Menarche normally occurs 2~ to 3 years after the first appearance of secondary sex characteristics. A delay of an additional12 to 18 months is within the normal range, but beyond this a diagnosis of amenorrhea can be made with sorne certainty. The pubertal years are a good time for the family physician to establish a relationship with the adolescent fe male that will carry over
readysource
Address reprint requests to Richard P. Dickey, MD, Suite 260, 9661 Lake Forest Blvd, New Orleans, LA 70127.
PEDIATRIC AND ADOLESCENT GYNECOLOGY
AUDIOVISUALS
DO
Delayed Puberty Greenberg 60-min tape, catalog #M-46 Source: Division of Continuing Education, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213 Cost: $5 Abnormal Sexuel Development Greenblatt, Drnowski 105 slides, catalog #02076 Source: Medcom, lnc, 1633 Broadway, New York, NY 10019 Cost: $75 Pediatrie Gynecology Fordney-Settage 60-min tape, catalog #PED-21-15
Vol. 60 • No. 4 • October 1976 • POSTGRADUATE MEDICINE
0
D
Source: Audio-Digest Foundation, 1250 S Glendale Ave, Glendale, CA 91205 Cost: $5.40, C-60 cassette or 5-in reel
BOOKS Endocrine and Genetlc Dlaeases of Chlldhood and Adolescence Gardner (Editer), ed 2. 1975 The Gynecology of Chlldhood and Adolescence Huffman, 1968 Publlsher: WB Saunders Co, Philadelphia Control of the Onset of Puberty Grumbach et al (Editors), 1974 Publlsher: John Wiley & Sons, Somerset, NJ
For information on how to use ReadySource. see page 171.
187
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Menstrual problems of the adolescent Richard P. Dickey To cite this article: Richard P. Dickey (1976) Menstrual problems of the adolescent, Postgraduate Medicine, 60:4, 183-187, DOI: 10.1080/00325481.1976.11714456 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714456
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 24 August 2017, At: 03:18
•
1pma annais
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
from the 60th interstate postgraduate medical assembly
• The age of men arche differs from one individual to another, as does the time required to reach reproductive maturity. The transition period may be a difficult time for the young girl involved, and the family physician or the pediatrician may be called on to interpret for both the girl and ber parents what is normal and what is. not. Problems of menstrual dysfonction are common during the first 18 months following menarche. In most instances they are short-lived or can be managed with simple medical treatment, but sorne are early manifestations of reproductive disorders which will persist throughout life. It is important for the physician to determine early which type of problem is involved, so that unnecessary treatment can be avoided and necessary treatment instituted. Events of Puberty
Pubertal changes occur at a constant rate in response · to hormonal stimulation. The usual sequence and approximate timing of changes are known (table 1), and variations can be used to predict possible problems. Estrogen-dependent changes appear at about the age of 11 years, with a range of 8 to 14 years. Fat deposition occurs in the hips and thighs, the breasts begin to develop, and the body of the girl begins to assume the mature female form. Within about four months, hair appears in the pu bic area and about six months later in the axillae; these are androgen-dependent characteristics. The beginning of breast development (the larche) and hair growth (adrenarche) precede by about a year the so-called growth spurt, which in tum occurs about 1V2 years before menarche. The timing of the onset of normal menarche is now thought to be related to weight and to height, an increase in both being necessary before menstruation can begin. Menarche occurs when the growth spurt be gins to level off, and it is estimated that the average girl will grow only about 21f2 inches more after menarche.
menstrual problems of the adolescent Richard P. Dlckey, MD Louisiana State University Medical School New Orleans
Pubertal changes occur at a constant rate and in a particular sequence; deviations are indicative of possible menstrual problems. Such problems include precocious puberty, amenorrhea, menstrual irregularity, cramps, and premenstrual tension. Of those patients with menstrual irregularity, 10% to 15% will have chronic conditions requiring lifelong treatment.
Precocious Puberty
Precocious puberty is now defined as the onset of menses before age 10. Very often it is familial. About 80% to 90% of girls affected are found to have no abnormality, while 3% to 5%
Vol. 60 • No. 4 • October 1976 • POSTGRADUATE MEDICINE
183
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
table 1. events of puberty Variable
Average age (years)
Range (years)
Breast growth
11
8-14
Growth of pubic and axillary hair
11
8-14
Growth spurt
12
9Y2·14Y2
Menarche
13Y2
10-16
From Dickey RP: Reproductive anatomy, physiology, and endocrinology. ln Esinman AW, Knox EG, Tyrer L (Editors): Seminar in Family Planning. Ed 2. Chicago, ArMerican Collage of Obstetrics and Gynecology, 1974. With permission.
have a lesion of the central nervous system, as in those with Albright's syndrome or who are mentally retarded. Of girls with early menarche, 10% to 15% have an ovarian tumor. Such a tumor may produce either estrogen or androgen; rarely it produces both. In most cases, the presence of menses and breast development without pubic and axillary hair is diagnostic of an estrogensecreting tumor. Androgen-producing tumors are uncommon and are associated with marked virilization or growth of pubic and axillary hair without breast development and usually no menses. This latter type of tumor may also occur in the adrenal gland.
Turner's syndrome. X-ray films of the long bones and epiphyses and also of the short bones of the wrist are valuable for detecting delayed bone development. If these films show a bone maturity of, say, 13'1.2 years (the average age for on set of menses) in a girl with normal secondary se x characteristics, menarche should be imminent. Absence of menarche for three years or more after the development of secondary sex characteristics may stem from an anomaly of the genital tract, such as an imperforate hymen, or from sorne failure of development of the uterus or the vagina. The presence of normal estrogen- and androgen-dependent secondary sex characteristics attests to normal functioning of the ovaries. If only estrogen-dependent characteristics are present, the patient may, in fact, be a male pseudohermaphrodite whose feminine characteristics result from a condition such as feminizing testes syndrome, in which testosterone produced by the testes is interpreted by cellular receptors as estrogen. In this syndrome the effects of androgen are completely lacking. On the other band, if only androgendependent characteristics are present, the patient may be a female pseudohermaphrodite, masculinization being caused by a tu mor, hyperplasia, or an enzyme defect of the adrenal gland.
Amenorrhea Menstrual lrregularlty
Since menarche usually occurs about 2'1.2 years after thelarche and adrenarche, a prediction of primary amenorrhea can be made earlierthan age 18, as in the case of a 16-year-old girl with no sign of breast or pubic and axillary hair development or a girl of the same age without menses in whom secondary sex characteristics began to develop at the age of Il or 12 years. Secondary sex characteristics may fail to appear because of a generalized delay in maturation due to such a pathologie state as hypothyroidism or congenital heart disease or to genetic defects such as that present in
About 10% to 15% of women have irregular menses and dysfunctional bleeding problems; usually these women also are infertile. Regular menses normally begin about 12 months after menarche, with a range of approximately 6 to 18 months. Absence of regular menstruation within 12 months after the first period is a cause for sorne worry; after 18 q~.onths the patient is known to be one of the 10% to 15% destined to have lifelong menstrual problems. Menstrual irregularity can be divided into three categories: (1) infrequent menses with
184
POSTGRADUATE MEDICINE • October 1976 • Vol. 60 • No. 4
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
hirsutism and virilization, (2) infrequent menses without hirsutism, and (3) hypermenorrhea. Infrequent menses, hirsutism, and virilization-The patient with this type of irregularity most likely has Stein-Leventhal syndrome, or what is now called the polycystic ovary syndrome, ie, ovaries unresponsive to gonadotropins and producing androgen in excessive amounts. However, there is a 15% chance that the problem is caused by mild adrenogenital syndrome, in which excess androgen is secreted by the adrenal gland, and a rare chance that a tumor is present. Evaluation should include determination of levels of 17-ketosteroid (to rule out adrenal tumor) and, if possible, of testosterone (to rule out ovarian tumor) and luteinizing hormone (LH) (characteristically elevated in polycystic ovary syndrome). A trial of clomiphene citrate (Clomid) is given initially in an attempt to regulate menstruation and establish a diagnosis of polycystic ovary syndrome. I have found that menses are regulated in about 90% of patients with this syndrome who are given clomiphene for 3 to 12 months, and that the period remains regular after therapy is discontinued. A second treatment is to place the patient on a regimen of oral contraception, whereby menses are regulated and ovarian production of abnormal amounts of androgen is halted. I feel this is one of the few instances in which use of an oral contraceptive is justified in girls who have recently begun menstruating. If there is no response to either of these regimens, the patient may be one of the 15% with mild adrenogenital syndrome and should be given a trial of adrenocorticosteroid therapy. Dexamethasone (Decadron, 0.5 mg at bedtime) has proved to be the most useful short-term treatment. Iftreatment is effective, the menstrual cycle will become normal within six to eight weeks, at which time 5 mg of prednisone can be substituted for the dexamethasone. Therapy may be discontinued
after one year with a good chance that normal cycles will continue. Infrequent menses without hirsutism-A patient with this type of menstrual irregularity sometimes also has galactorrhea. The syndrome is usually caused by hypothalamic insufficiency and more rarely by pituitary insufficiency or pituitary adenoma. Extensive evaluation is required, with attention focused on thyroid function and on fas ting blood sugar level if diabetes mellitus is found in the family his tory. (However, about 50% of patients who become diabetic have no family history of this disease.) A complete white blood cell count and radioimmunoassays of serum LH and follicle-stimulating hormone (FSH) should be done to check for premature ovarian failure and for pituitary adenoma. Skull x-ray films should be made, again to rule out pituitary tumor. If possible, serum prolactin levels should be measured. If menses cease entirely (or never began), a chromosomal analysis should be obtained. If the workup fails to disclose any organic cause for menstrual irregularity, watchful waiting is the best policy. The use of oral contraception is not recommended in these patients. Hypermenorrhea-Excessive bleeding is the most frequent complaint associated with irregular menstruation. The cause is usually hypothalamic immaturity: The hypothalamus and the pituitary do not yet respond normally to feedback of ovarian estrogen and thus estrogen secretion is irregular . ..,..
Vol. 60 • No. 4 • October 1976 • POSTGRADUATE MEDICINE
185
table 2. organic causes of hypermenorrhea System le Blood dyscrasia Diabetes Thyroid disorders
Reproductive organs Endometrial or cervical polyps Vaginal or cervical neoplasm Abnormal pregnancy
Cramps are a common problem associated with menstruation. They usually do not begin until regular ovulation begins, 10 to 14 months after menarche. Their appearance signais that progesterone is being produced by the corpus luteum in the luteal phase of the cycle.
It is now believed that prostaglandins are the primary cause of menstrual cramps. Prostaglandins are produced in the endometrium and myometrium, and their release is thought to cause nausea, cramping, and pain. These typical menstrual symptoms have been produced when prostaglandins have been administered in connection with other medical problems. Rarely, blood clots or cervical stenosis will be found as the causative agent. A pelvic or rectal examination should be done to ascertain that the uterus and ovaries are normal. If cramps result from prostaglandin production, aspirin, which is a prostaglandin antagonist, will be useful as therapy and may also reduce menstrual blood loss. Not surprisingly, aspirin is a major component of most patent medicines for dysmenorrhea. (Most old-time ''female'' patent medicines contained ethyl alcohol; Lydia Pinkhams, before prohibition, was 40 proof. A glass of wine is also effective. Ethyl alcohol tums off the oxytocin-producing centers in the pituitary.) A second treatment for menstrual cramps is amphetamine. It is thought to act as an antagonist to prostaglandin, or possibly as an agonist to the adrenergic system, which in tum antagonizes prostaglandin. I give dextroamphetamine sulfate in a dosage of 5 mg every four to six hours for severe menstrual cramps. Progestogen is also effective when given for five to seven days before the onset of menses. Menstrual cramps are extremely rare in women using oral contraception. However, it is not necessary to give a pill for 21 days to treat a condition that only lasts three or four days. I give a pure progestogen (Micronor or Nor-Q.D., 0.35 mg) five days before the expected onset of menses (if cycles are regular) or at the first sign of premenstrual tension. The patient takes one or two tablets per day for five days. Other progestogens (Duphaston, Lo/Ovral, Norlutate, Provera) also are effective.
186
POSTGRADUATE MEDICINE • October 1976 • Vol. 60 • No. 4
Richard P. Dlckey
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
Dr. Dickey is clinical associate professor of obstetrics and gynecology, Louisiana State University Medical School, New Orleans.
Table 2 lists possible organic causes of hypermenorrhea; these conditions are seen rarely. A pelvic examination with use of a speculum is always necessary. Thyroid function studies should be done and a complete blood count made. If possible, levels of FSH and LH should be determined. Treatment for hypermenorrhea begins with a high dose of estrogen to stop the acute bleeding. I recommend conjugated estrogens (Premarin), 20 mg given intramuscularly, with the dose repeated in four hours if necessary. An intensive regimen of oral contraception is begun at the same time to suppress endometrial proliferation and to develop the blood vessels in the endometrium. I find a combination contraceptive, such as Ovulen, works weiL To effect this so-called medical curettage, two pills a day should be given for seven to ten days. Withdrawal flow will be unsatisfactory if the period of administration is shorter; longer administration is seldom necessary. In a patient who must be chronically treated, a progestogen in tablet form, such as norethindrone acetate (Norlutate), dydrogesterone (Duphaston), or medroxyprogesterone acetate (Provera), or any of the oral contraceptives containing progestogen may be given in double the normal dose for the last seven days of each cycle. Dilatation and curettage are rarely necessary. Menstrual Cramps
Downloaded by [Australian Catholic University] at 03:18 24 August 2017
Premenstruel Tension
ihto ber adult years. If possible, Pap tests should be begun l;lt this time. The test is easily accomplished in a young girl without the use of a speculum: A cotton-tipped applicator is moistened in a saline solution and inserted through the hymen. A speculum is also not required for a pelvic examination except in cases of persistent abnormal bleeding. Oral èontraception is used sparingly in pubertal adolescents. It is never used to start menstruation in a patient with delayed menarche whose problem bas not been diagnosed. Approximately 1% to 3% of women who use oral contraception will have persistent amenorrhea on discontinuing the drug. In most cases, these are women who had irregular menses beginning in adolescence, and many of them have used oral contraception since their early teens. In dealing with menstrual problems in adolescents, wisdom and patience are prime requisites, as is also the ability to recognize normal variation and to diagnose promptly abnormal events or delays of events. •
Premenstrual tension occurs only in patients with ovulatory cycles and in patients who are taking a birth control pill with an amount of progestogen excessive for their particular physiologie makeup. It is thus thought to be due principally to sodium and water retention, caused by the cyclic drop in luteal progesterone production. Immediate treatment would appear to be use of a low-salt diet and a diuretic; both of these do work. Paradoxically, progestogen given in low doses for five tose ven days before the onset of menses also seems to prevent premenstrual tension. Comment
Menarche normally occurs 2~ to 3 years after the first appearance of secondary sex characteristics. A delay of an additional12 to 18 months is within the normal range, but beyond this a diagnosis of amenorrhea can be made with sorne certainty. The pubertal years are a good time for the family physician to establish a relationship with the adolescent fe male that will carry over
readysource
Address reprint requests to Richard P. Dickey, MD, Suite 260, 9661 Lake Forest Blvd, New Orleans, LA 70127.
PEDIATRIC AND ADOLESCENT GYNECOLOGY
AUDIOVISUALS
DO
Delayed Puberty Greenberg 60-min tape, catalog #M-46 Source: Division of Continuing Education, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213 Cost: $5 Abnormal Sexuel Development Greenblatt, Drnowski 105 slides, catalog #02076 Source: Medcom, lnc, 1633 Broadway, New York, NY 10019 Cost: $75 Pediatrie Gynecology Fordney-Settage 60-min tape, catalog #PED-21-15
Vol. 60 • No. 4 • October 1976 • POSTGRADUATE MEDICINE
0
D
Source: Audio-Digest Foundation, 1250 S Glendale Ave, Glendale, CA 91205 Cost: $5.40, C-60 cassette or 5-in reel
BOOKS Endocrine and Genetlc Dlaeases of Chlldhood and Adolescence Gardner (Editer), ed 2. 1975 The Gynecology of Chlldhood and Adolescence Huffman, 1968 Publlsher: WB Saunders Co, Philadelphia Control of the Onset of Puberty Grumbach et al (Editors), 1974 Publlsher: John Wiley & Sons, Somerset, NJ
For information on how to use ReadySource. see page 171.
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