Oligomenorrhea
In most women, menstrual bleeding occurs every 28 days plus or minus 4 days. Although some variation is normal, menstrual bleeding at intervals of greater than 36 days may indicate oligomenorrhea—abnormally infrequent menstrual bleeding characterized by three to six menstrual cycles per year. When menstrual bleeding does occur, it’s usually profuse, prolonged (up to 10 days), and laden with clots and tissue. Occasionally, scant bleeding or spotting occurs between these heavy menses.
Oligomenorrhea may develop suddenly or it may follow a period of gradually lengthening cycles. Although oligomenorrhea may alternate with normal menstrual bleeding, it can progress to secondary amenorrhea.
Because oligomenorrhea is commonly associated with anovulation, it’s common in infertile, early postmenarchal, and perimenopausal women. This sign usually reflects abnormalities of the hormones that govern normal endometrial function. It may result from ovarian, hypothalamic, pituitary, and other metabolic disorders, and from the effects of certain drugs. It may also result from emotional or physical stress, such as sudden weight change, debilitating illness, or rigorous physical training.
History and physical examination
After asking the patient’s age, find out when menarche occurred. Has the patient ever experienced normal menstrual cycles? When did she begin having abnormal cycles? Ask her to describe the pattern of bleeding. How many days does the bleeding last, and how frequently does it occur? Are there clots and tissue fragments in her menstrual flow? Note when she last had menstrual bleeding.
Next, determine if she’s having symptoms of ovulatory bleeding. Does she experience mild, cramping abdominal pain 14 days before she bleeds? Is the bleeding accompanied by premenstrual symptoms, such as breast tenderness, irritability, bloating, weight gain, nausea, and diarrhea? Does she have cramping or pain with bleeding? Also, check for a history of infertility. Does the patient have any children? Is she trying to conceive? Ask if she’s currently using hormonal contraceptives or if she’s ever used them in the past. If she has, find out when she stopped taking them.
Then ask about previous gynecologic disorders such as ovarian cysts. If the patient is breast-feeding, has she experienced any problems with milk production? If she hasn’t been breast-feeding recently, has she noticed milk leaking from her breasts? Ask about recent weight gain or loss. Is the patient less than 80% of her ideal weight? If so, does she claim that she’s overweight? Ask if she’s exercising more vigorously than usual.
Screen for metabolic disorders by asking about excessive thirst, frequent urination, or fatigue. Has the patient been jittery or had palpitations? Ask about headache, dizziness, and impaired peripheral vision. Complete the history by finding out what drugs the patient is taking.
Begin the physical examination by taking the patient’s vital signs and weighing her. Inspect for increased facial hair growth, sparse body hair, male distribution of fat and muscle, acne, and clitoral enlargement. Note if the skin is abnormally dry or moist, and check hair texture. Also, be alert for signs of psychological or physical stress. Rule out pregnancy by a blood or urine pregnancy test.
Medical causes
Adrenal hyperplasia
In this disorder, oligomenorrhea may occur with signs of androgen excess, such as clitoral enlargement and male distribution of hair, fat, and muscle mass.
Anorexia nervosa
Anorexia nervosa may cause sporadic oligomenorrhea or amenorrhea. Its cardinal symptom, however, is a morbid fear of being fat associated with weight loss of more than 20% of ideal body weight. Typically, the patient displays dramatic skeletal muscle atrophy and loss of fatty tissue; dry or sparse scalp hair; lanugo on the face and body; and blotchy or sallow, dry skin. Other symptoms include constipation, decreased libido, and sleep disturbances.
Diabetes mellitus
Oligomenorrhea may be an early sign in this disorder. In juvenile-onset diabetes, the patient may have never had normal menses. Associated findings include excessive hunger, polydipsia, polyuria, weakness, fatigue, dry mucous membranes, poor skin turgor, irritability and emotional lability, and weight loss.
Hypothyroidism
Besides oligomenorrhea, this disorder may result in fatigue; forgetfulness; cold intolerance; unexplained weight gain; constipation; bradycardia; decreased mental acuity; dry, flaky, inelastic skin; puffy face, hands, and feet; hoarseness; periorbital edema; ptosis; dry, sparse hair; and thick, brittle nails.
Polycystic ovary disease
About 25% of women with polycystic ovary disease have oligomenorrhea; but some may have amenorrhea, menometrorrhagia, or irregular menses. Infertility, anovulation, and enlarged, palpable ovaries are also common. Other features vary but may include signs of androgen excess—male distribution of body hair and muscle mass, facial hair growth, acne and, occasionally, obesity.
Prolactin-secreting pituitary tumor
Oligomenorrhea or amenorrhea may be the first sign of a prolactin-secreting pituitary tumor. Accompanying findings include unilateral or bilateral galactorrhea, infertility, loss of libido, and sparse pubic hair. Headache and visual field disturbances—such as diminished peripheral vision, blurred vision, diplopia, and hemianopsia—signal tumor expansion.
Sheehan’s syndrome
This pituitary necrosis usually follows severe obstetric hemorrhage. Oligomenorrhea or amenorrhea may occur with failure to lactate, sparse pubic and axillary hair, decreased libido, and fatigue.
Thyrotoxicosis
This disorder may produce oligomenorrhea along with reduced fertility. Cardinal findings include irritability, weight loss despite increased appetite, dyspnea, tachycardia, palpitations, diarrhea, tremors, diaphoresis, heat intolerance, an enlarged thyroid and, possibly, exophthalmos.
Other causes
Drugs
Drugs that increase androgen levels—such as corticosteroids, corticotropin, anabolic steroids, danocrine, and injectable and implanted contraceptives—may cause oligomenorrhea. Hormonal contraceptives may be associated with delayed resumption of normal menses when their use is discontinued; however, 95% of women resume normal menses within 3 months. Other drugs that may cause oligomenorrhea include phenothiazine derivatives and amphetamines, and antihypertensive drugs, which increase prolactin levels.
Special considerations
Prepare the patient for diagnostic tests, such as blood hormone levels, thyroid studies, or pelvic imaging studies.
Pediatric pointers
Teenage girls may experience oligomenorrhea associated with immature hormonal function. However, prolonged oligomenorrhea or the development of amenorrhea may signal congenital adrenal hyperplasia or Turner’s syndrome.
Geriatric pointers
Oligomenorrhea in the perimenopausal woman usually indicates impending onset of menopause.
Patient counseling
Ask the patient to record her basal body temperature to determine if she’s having ovulatory cycles. Provide her with blank charts, and teach her how to keep them accurately. Have the patient use a home ovulation testing or urine luteinizing hormone kit to provide evidence of ovulation. Remind the patient that she may become pregnant since ovulation may still occur even though she isn’t menstruating normally. Discuss contraceptive measures, as appropriate.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Amenorrhea
» Next page: Amenorrhea (Professional Guide to Signs & Symptoms (Fifth Edition))
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