Psychological and physical disorders of the menstrual cycle

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Chapter 29 Psychological and physical disorders of the menstrual cycle

MOOD AND PHYSICAL SYMPTOMS IN THE MENSTRUAL CYCLE

In the proliferative phase of the menstrual cycle few problems occur. Some women experience lower abdominal pain, which is unilateral and occurs at the time of ovulation. The pain is usually not severe and lasts for 12 hours or less. The condition is called mittelschmerz. It indicates that ovulation has occurred, but investigations show no intra-abdominal pathology. If mittelschmerz is recurrent and distressing, relief can be obtained if the woman takes a hormonal contraceptive.

Most women in the reproductive years experience some psychological (negative mood) or physical symptoms in the luteal phase of the menstrual cycle. The symptoms vary in character and tend to become worse as menstruation approaches. They do not occur in every cycle, and may vary in intensity in different cycles. A few women have severe mood and physical symptoms; a diagnosis of premenstrual syndrome (PMS) or premenstrual dysphoric disorder is made in these cases.

PREMENSTRUAL SYNDROME

Premenstrual syndrome (premenstrual dysphoric disorder)

In 5–15% of women, who are usually aged in their late 20s or early 30s (range 20–40), the negative mood and physical changes occurring in the luteal phase are sufficiently severe to affect day-to-day living and social and personal relationships, particularly with partners and children, most or all months. With the onset of menstruation, or during it, the symptoms disappear. During the postmenstrual period, for at least a week the woman feels well, sometimes euphoric, but with – or soon after – ovulation the symptoms reappear.

The symptoms vary in character and in severity in different menstrual cycles, but there is always a symptom-free interval of at least 1 week. The mood changes tend to cluster together and are described as irritable, depressive, anxious and tense, with mood swings and feelings of being out of control, fatigued and lacking motivation. Different women will describe slightly different symptoms as the most problematic. This may depend on the woman’s country of birth and her current lifestyle and stresses. The same symptoms can be reported by women taking oral contraception just before and during the pill-free week; the symptoms are usually mild.

Diagnosis of PMS

The diagnosis of PMS is made after evaluating the periodicity of the physical and mood symptoms, ascertaining that there is a symptom-free period after menstruation, and ensuring that the symptoms cannot be explained by some other illness. Other illnesses can be exacerbated during the luteal phase of the menstrual cycle, and this can lead to inaccuracies in the diagnosis. The suspected diagnosis should be confirmed by asking the woman to complete a daily record of symptoms over three menstrual cycles (Fig. 29.1). As well as establishing a firm diagnosis, the value of the daily record is that the woman develops an insight into her symptoms and is encouraged by the fact that the medical practitioner has an interest in her problems.

Fig. 29.1 Menstrual history diary.

Aetiology of PMS

The aetiology of PMS is unknown (Box 29.1). It is reported to be more severe if the woman is under stress. There may be a genetic component, but the current theory is that PMS is multifactorial. One underlying abnormality may be a fluctuation in the levels of oestradiol in the luteal phase, which may cause the symptoms directly or by decreasing brain serotonin activity. A problem in accepting this theory is that no consistent fluctuations have been detected with daily monitoring. PMS does not occur if the ovaries are absent.

Box 29.1 PMS summary

What is PMS?	Negative mood and physical symptoms commencing after ovulation and resolving during the luteal phase of the menstrual cycle. There must be at least 7 days free of symptoms each month and the symptoms must be of sufficient severity to affect the woman’s lifestyle
Aetiology	Unknown
Prevalence	All women have cyclical changes in symptoms; 5–15% of women in their 20s and 30s have moderate to severe symptoms
Diagnosis	By history and examination, daily diary, and excluding other causes for the symptoms
Symptoms	Mood: irritability, depression, sadness, fatigue, labile mood, anxious, tense Physical symptoms: breast swelling and soreness, abdominal swelling and discomfort, headache and backache and increased appetite

Management

Taking a very good medical and psychosocial history and discussing management with the woman

Psychological: cognitive behavioural therapy to help the woman understand her symptoms and make changes to reduce stress and the factors exacerbating her symptoms. Keeping a daily diary to help understand the symptoms and their changing severity each month assists both diagnosis and management

Hormonal: oral contraception or continuous low-dose oestrogen and progestogen

Other medication: SSRIs, lowest dose available continuously or during luteal phase

Surgical: removal of the ovaries is of theoretical interest only

Outcome Unknown

Management of PMS

The importance of obtaining a thorough history and an ongoing therapeutic relationship with the woman cannot be overestimated. Once this has been established, explanation and counselling will be accepted. The woman’s lifestyle should be explored and suggestions made to reduce stress. The predominant symptoms should be identified from the completed charts and treatment directed to specific problems, for example regular ‘normal’ eating during the follicular phase may prevent overeating or binge eating premenstrually.

Many medications and ‘natural cures’ including evening primrose oil, Chinese herbal medications and progesterone have been tried, but in spite of enthusiastic reports Cochrane reviews have not demonstrated that they are more effective than placebo.

Three approaches have been suggested for women who have severe, intractable PMS. The first is to prescribe a hormonal contraceptive. The pill (monophasic pill) has been prescribed for some years, with varying rates of success in relieving PMS. Some women suffering severe symptoms find they ‘react badly’ to the pill, whereas others find relief, particularly if the active tablets are taken continuously (pill-free week excluded). Transdermal oestrogen patches or an oestrogen implant suit some women better. In these cases the woman has to be protected from the development of endometrial carcinoma due to the presence of unopposed oestrogen, and a progestogen is prescribed cyclically. During the period when the progestogen is taken symptoms of PMS may recur, and so continuous progestogen may be preferred. The second approach is to prescribe a selective serotonin reuptake inhibitor (SSRI) in the lowest dose available, either continuously or during the luteal phase. The mode of action of SSRIs in relieving symptoms of PMS is unknown but has been shown to be highly effective in reducing the physical, functional and behavioural symptoms of moderate to severe PMS. The third approach is radical and not recommended, being either to suppress ovarian activity with gonadotrophin-releasing hormone agonists or to perform a bilateral oophorectomy (and total hysterectomy).

FUNCTIONAL BOWEL DISEASE

Irritable bowel syndrome

Symptoms of irritable bowel syndrome (IBS) and other disorders of gastrointestinal function may be exacerbated premenstrually. IBS affects 14–24% of women, although a clinical diagnosis is made in only 1–2% of the population. A patient with IBS may complain of abdominal pain associated with a change in bowel habit (diarrhoea, constipation, or alternating between the two), and symptoms of abdominal bloating, passage of mucus, and feelings of incomplete evacuation. It is currently believed that IBS and other disorders of gastrointestinal function result from an interplay of altered gut motility, increased sensitivity of the intestine or colon, and psychosocial factors. Food intake and prior gastrointestinal infection may also play a role. Diagnosis is based on a positive symptom diagnosis, and investigations should be made to exclude organic disease, particularly in the elderly. Treatment, although often unsatisfactory, is tailored to reduce the dominant symptom: dietary fibre for constipation; opioid agents for diarrhoea; and low-dose antidepressants or infrequent use of antispasmodics for pain. Psychotherapy and hypnotherapy have not been shown in Cochrane reviews to be of definitive benefit. The patient needs reassurance that she is not suffering from cancer or a serious bowel disease, and extensive investigations or referrals are not usually warranted.

CHRONIC PELVIC PAIN

A few women complain of chronic pain in the lower abdomen and pelvis which fluctuates in intensity and tends to increase in the premenstruum. It may occur on either side of the abdomen and may be felt on different sides at different times. The woman may also complain of deep dyspareunia or a postcoital pelvic ache, which may last for 24 hours. The woman may have a history of several episodes of ‘pelvic inflammatory disease’ which have been diagnosed on clinical findings rather than by laparoscopy, and she may have had episodes of pelvic surgery.

The diagnosis is made after excluding organic causes of chronic pelvic pain, such as adenomyosis, endometriosis and pelvic inflammatory disease, which are present in about one-third of cases. This indicates that laparoscopy is mandatory to make a diagnosis. The procedure should be made during menstruation to disclose endometriotic lesions deep in the cul-de-sac when the lesion is most likely to be seen. Two studies in the USA showed that over half of the women who had chronic pelvic pain had been severely sexually abused (penetration or other contact with the patient’s vagina or anus) before the age of 15, and 42% had also been physically abused. These issues are worth exploring.

In some cases chronic pelvic pain is associated with an ovarian remnant that was left behind after hysterectomy and bilateral oophorectomy.

Treatment

The investigations themselves may constitute a form of treatment, as in one study of 60 women in whom laparoscopy showed no pathology, 90% of the patients assessed 6 months later said that, since the laparoscopy, they had no pelvic pain or that there was much less pain.

The woman’s psychological, marital and psychosexual problems need to be explored and supportive psychotherapy offered. Referral to a pain clinic may be useful. If the woman asks for medications, medroxyprogesterone 30 mg/day may be prescribed. An alternative is to prescribe danazol 200 mg three times daily for 2–3 months, although the side-effects may deter the woman from taking this treatment. Antidepressant medication, particularly selective serotonin reuptake inhibitors (SSRIs), may help some women.

DYSMENORRHOEA

Dysmenorrhoea means painful menstruation. Two types are described: primary, or spasmodic dysmenorrhoea, and secondary dysmenorrhoea.

Primary dysmenorrhoea

This form usually starts 2–3 years after the menarche and is maximal between the ages of 15 and 25. It decreases with age and usually ceases after childbirth. The crampy pains start during the 24 hours before menstruation and may last 24–36 hours, although they are only severe for the first 24 hours. The cramps are felt in the lower abdomen, but may radiate to the back or down the inner surface of the thighs. In severe cases vomiting or diarrhoea may accompany the cramps.

Spasmodic dysmenorrhoea is experienced by 60–75% of young women. In three-quarters of affected women the cramps are minor or moderate in severity, but in 25% they are severe and incapacitating.

The aetiology of spasmodic dysmenorrhoea has now been clarified. When progesterone is secreted following ovulation, the luteinized endometrium is able to synthesize prostaglandins. If the balance between prostacyclin (which causes vasodilatation and myometrial relaxation), prostaglandin F_2α (which causes vasoconstriction and myometrial contraction) and prostaglandin E₂ (which causes myometrial contraction and vasodilatation) is disturbed, causing PGF_2α to predominate, myometrial ischaemia (uterine angina) and uterine hypercontractility occur. In addition, vasopressin is involved in dysmenorrhoea. Vasopressin increases prostaglandin synthesis and may act on the uterine arteries directly.

Treatment

Treatment consists of suppressing ovulation, by prescribing an oral contraceptive or by inhibition of prostaglandin synthesis by one of the prostaglandin synthetase inhibitors, mefenamic acid, ibuprofen, diclofenac sodium or naproxen. There appears to be little difference in their effectiveness.

• Oral contraceptives may be preferred by a woman who is sexually active, as the pill will protect her against an unwanted pregnancy as well as relieving the dysmenorrhoea.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) may be preferred by women who do not wish to use hormones and prefer to take medication for as short a time as possible. The chosen medication is taken at the first sign of pain and continued for up to 5 days.

Dysmenorrhoea is relieved in 95% of cases, whether oral contraceptives or NSAIDs are chosen. If the chosen treatment fails to relieve the dysmenorrhoea, an alternative can be tried.

Secondary dysmenorrhoea

Secondary, or acquired, dysmenorrhoea is unusual before the age of 25 and uncommon before the age of 30. In most cases the underlying cause is either endometriosis or pelvic inflammatory disease. Typically, the cramps start 2 or more days prior to menstruation, and the pain increases in severity until late menstruation, when it peaks, taking 2 or more days to cease. The management is that of the primary condition.

EATING AND EXERCISE DISORDERS

The presence of an eating or exercise disorder may have profound effects on the health and wellbeing of a woman throughout her reproductive life and on the development of her child. The aim of this section is not to describe in detail eating and exercise disorders but to alert the medical practitioner to the need to ask a few questions about a woman’s body weight (BMI) and her eating and exercise behaviour. Eating and exercise problems are associated with delayed menarche, secondary amenorrhoea, infertility, miscarriage, low-birthweight (premature and growth-restricted) babies, postpartum depression, pelvic pain and irritable bowel, sexual problems and polycystic ovarian syndrome and osteoporosis. The doctor is easily alerted to the possibility of a disorder if women are very thin or obese, but many disordered women have a body weight in the normal range. Most gynaecological and obstetric problems are reversed if the woman seeks help and recovers from her eating disorder. Some women may not be aware they have an eating or exercise problem, and may need encouragement to talk about their behaviour and possible treatments. Other women who are aware that their behaviour and thinking are disordered may prefer to seek alternative remedies and undergo assisted conception or medications for their medical complications; these women need careful and regular medical monitoring.

PSYCHOLOGICAL SYMPTOMS AFTER HYSTERECTOMY AND OOPHORECTOMY

In recent years the frequency of hysterectomy has fallen as other methods of treatment for conditions previously treated by hysterectomy have been developed. The effects of the operation depend on the condition that led to the hysterectomy, and the woman’s knowledge and attitude to hysterectomy. Some women recover quickly, others are mildly or moderately incapacitated for up to 3 months. One-third of women take 3 months to recover fully from the operation, and 20% take longer. Five to ten per cent of women feel well generally but have bowel or bladder symptoms, particularly genuine stress incontinence, which may persist for months.

Although most gynaecologists choose total hysterectomy so that cervical cancer will not develop, there is a small trend back to subtotal hysterectomy in selected cases. The reasons for this are:

• The operation is less dangerous as the ureters are avoided.

• The sequelae of bowel and bladder symptoms occur less frequently.

• The woman’s sexual response, sexual enjoyment and orgasm are less negatively affected.

• The risk of developing cervical cancer is very small if a woman has had regular cervical smears which have always been normal and she continues to have regular smears. If any cervical cell abnormality is detected it will be early, and conization or other local treatment can be offered.

Most women understand and respond well to removal of an organ that is ‘diseased’ or dysfunctional. They do not necessarily agree with the removal of reproductive organs for prophylactic reasons, or which could be preserved if another treatment is equally as effective.

Hysterectomy

Some women after hysterectomy become anxious and distressed. This is more likely to occur if the woman believes that her body image, her femininity and her sexual attractiveness are reduced. Such anxiety follows misconceptions about hysterectomy, including notions that:

• A woman will be unable to have or enjoy sexual intercourse because her vagina will be shorter.

• She will become obese.

• She will be severely depressed after the operation.

• She will become postmenopausal.

The patient should be reassured about the first two misconceptions before the operation takes place. The third misconception is untrue. There is no evidence that hysterectomy increases clinical depression, unless the woman had a history of depression prior to surgery. The fourth misconception is only likely to be true if she has her ovaries removed at the operation, or if the surgeon has damaged the ovarian blood supply.

Oophorectomy

Some women after loss of their ovaries will also feel incomplete as a woman, a loss of femininity and of sexual interest. Her feelings can be intense if she did not feel she had a chance to discuss this with her doctor, and was unaware she would need to take hormone replacement for the symptoms of menopause.

The question of bilateral oophorectomy of normal ovaries at the time of hysterectomy is contentious. Ovarian extirpation is not usually carried out in women under 45, but some gynaecologists perform it in older women. Their reasons are, first, that if the ovaries are left, 1 in 1000 women will develop ovarian cancer, and second, the ovaries have no function after the menopause (although they do produce DHEA (dehydroepiandrosterone)). There are also data to the effect that up to 20% of women aged 40–45 experience ovarian failure within 3 years of hysterectomy.

Bilateral oophorectomy at the time of hysterectomy is associated with severe menopausal symptoms requiring hormone replacement treatment (see p. 325). Women may wish to try to avoid taking hormones and wait for the ‘natural’ menopause, when their symptoms may be less severe.

The woman should make her own decision, after discussion with her doctors and after she has had time to think it over and seek other advice if she wishes.

Hysterectomy is safe today, but as it is not without morbidity, alternative therapies should be considered.

To reduce the psychological and physical problems that may occur after hysterectomy, the attending doctors, whether specialists or GPs, must talk with the woman and her partner. The reason for the operation should be explained, its extent described, alternative treatments discussed, and problems that may arise mentioned. In most cases the woman should be given time to think about the discussion and to ask further questions, if she has any, before the operation is performed.

Related

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