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Amenorrhea and Dysmenorrhea
Amenorrhea, the absence of menstrual flow, is often attributed to anatomic abnormalities, genetic disorders, endocrine disorders, medication use, illegal drug use, or oral contraceptives. The disorder can be divided into primary and secondary disorders. Primary amenorrhea is when menarche never occurred, whereas secondary amenorrhea is the result of a cessation of menstruation in an individual who previously experienced a menstrual cycle (Hubert and VanMeter, 2018). Dysmenorrhea results from painful menstruation and also has primary and secondary features. Primary dysmenorrhea occurs when ovulation starts, and secondary dysmenorrhea develops from pelvic disorders such as endometriosis, uterine polyps or tumors, or pelvic inflammatory disease (Hubert and VanMeter, 2018).
Common Presenting Symptoms
Primary amenorrhea symptoms include the absence of menstruation in which an individual has never had a menstrual cycle. The main symptom is absence of the menstrual cycle, but can also include headache, visual changes, nausea, extra facial hair, hair loss, changes in breast size, and milky fluid or discharge from the breasts (American Academy of Family Physicians, 2020). Secondary amenorrhea is the cessation of menstruation in an individual who previously experienced menstrual cycles. The primary symptom is missing several menstrual cycles in a row, and the same symptoms of primary amenorrhea.
Patients experiencing primary and secondary dysmenorrhea may experience discomfort the day before and during the first 24-48 hours of menses which can be cyclic, acyclic, and/or accompanied by urinary or bowel symptoms; nausea, vomiting, diarrhea, headaches, and muscle cramps can also accompany the disorder (Sachedina and Todd, 2019). Secondary dysmenorrhea symptoms include progressively worsening pain, chronic pelvic pain, midcycle or acyclic pain, and irregular or heavy menstruation (Sachedina and Todd, 2019).
Primary amenorrhea is routinely diagnosed by performing a history and physical on the patient and collecting a series of labs for evaluation. Providers routinely perform a pregnancy test initially to rule out pregnancy as the underlying cause of amenorrhea. Other labs for evaluation include serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid – stimulating hormone (TSH), and prolactin levels (Klein, Paradise, and Reeder, 2019). Providers may decide to perform a pelvic ultrasound or magnetic resonance imaging (MRI) to identify abnormal reproductive anatomy or to detect an androgen-secreting tumor (Klein et al., 2019). If the pregnancy test is negative, evaluation of the hormone levels will assist in diagnosing the cause of amenorrhea, such as hypothalamic dysfunction, outflow tract obstruction, ovarian insufficiency, or chromosomal defects.
Secondary amenorrhea is routinely diagnosed in a similar manner beginning with a complete history and physical, review of medications, including contraceptives and illicit drugs. Patients are also given a pregnancy test and blood collected to evaluate the same hormonal levels as primary amenorrhea. If the pregnancy test is negative, evaluation of the hormone levels is performed to discover a diagnosis. Depending on the results of the hormone levels, the cause of secondary amenorrhea can be attributed to hypothalamic disorder, hyperandrogenism, metabolic syndrome, primary ovarian insufficiency, natural menopause, or chronic disease. Patients could also have other disorders which would be visualized on an ultrasound of MRI, including neoplasm, polycystic ovarian syndrome, or tumors of the adrenal or ovaries (Klein et al., 2019).
Primary and secondary dysmenorrhea are diagnosed in a similar fashion as amenorrhea. The health care provider should begin with a complete history and physical including the age of menarche, duration of menses, amount of bleeding, time elapsed between onset of menarche and dysmenorrhea. An evaluation of pain should include the onset, duration, severity, aggravating and alleviating factors, and when it occurs in relation to the menstrual cycle, dyspareunia, history of sexually transmitted or pelvic infections, and sexual violence (Sachedina and Todd, 2019). Providers would also complete an examination of the pelvis to determine the exact location of the pain and internal pelvic examination for the determination of tenderness on palpation.
Standard Treatment Plan
The standard treatment plan for primary amenorrhea depends on the underlying cause. If the individual does not have any underlying conditions, obstruction or congenital abnormalities, then the provider may recommend waiting for the menstrual cycle to start especially if there is a family history of late onset menstruation. Individuals with genetic or chromosomal abnormalities may require surgery. For secondary amenorrhea, birth control pills or other hormonal medications may be required to restart the menstrual cycle, or medication to stimulate ovulation. Estrogen replacement therapy is an option for women with an imbalance of hormonal levels. Patients experiencing a pituitary tumor may be prescribed medications to shrink it. Surgical management is uncommon but can be performed in the presence of uterine scarring by performing a hysteroscopic resection in order to restore the menstrual cycle (Eunice Kennedy Shriver National Institute of Child Health and Human Development, 2017).
Treatment for primary and secondary dysmenorrhea can include Nonpharmacological and pharmacological regimens such as application of heat, exercise, or medications such as nonsteroidal anti-inflammatory (NSAID) medications such as Ibuprofen or Advil, and oral contraceptives (Hubert and VanMeter, 2018).
Link(s) to Routine Screening and Treatment Guidelines
Routine screening is not recommended for amenorrhea or dysmenorrhea. In primary amenorrhea, individuals are not evaluated for the condition unless there is an absence of menses and secondary sexual characteristics by the age of fourteen; or the absence of menses by the age of sixteen, regardless of the presence of normal growth and development (Lowdermilk, Perry, Cashion, and Alden, 2016). For secondary amenorrhea, evaluation is not completed unless the individual has missed several menstrual cycles in a row unless they are determined to be pregnant.
Primary and secondary dysmenorrhea have the same guidelines as amenorrhea. Routine screening is not recommended. Individuals are evaluated if they exhibit symptoms. Treatment guidelines depend upon the causative factors for the discomfort. Individuals can be referred to the following links for treatment options for primary or secondary dysmenorrhea:
Breast cancer is the malignant growth of abnormal cells in the breast tissue. Most breast cancers begin in the milk ducts that supply milk to the nipple while others may originate in the glands that produce breast milk. Less common breast cancers include phyllodes tumors and angiosarcoma (American Cancer Society, 2020). The majority of breast cancer cases occur in women over the age of fifty. Familial history supports a strong genetic predisposition of the development of breast cancer and is connected to the BRCA-1 and BRCA-2 genes. Hormonal connection, specifically Estrogen is also strongly supported. Experiences such as early onset of menstruation and late onset of menopause, nulliparity, or advanced age with first childbirth all increase length of time to high level Estrogen exposure, increasing risk for developing breast cancer (Hubert &VanMeter, 2020). Early detection is key in treating breast cancer and the prevention of breast cancer spreading to other organs of the body.
Most patients present due to an abnormal mammogram. However, the presence of a breast mass undetected on a mammogram or formed between screenings account for 45% of identified breast cancer masses (Joe, 2020). The classic characteristics of a cancerous mass are hard, singular, non-moveable with irregular boarders. If the mass advances the patient may present with axillary adenopathy or changes in the skin to include erythema and dimpling of the skin known as peau d’orange (Joe, 2020). A patient may also notice retraction of the nipple or a discharge from the nipple (Hubert & VanMeter, 2018). If a breast mass is identified during a self-breast exam or due to visual changes to the breast or axillary area, the patient will need to see a physician to determine the nature of the mass and malignancy.
A majority of breast cancer masses are identified via mammography studies. Supplemental mammographic views and possible ultrasound conduction will be used for further identification and characterization. The BI-RADS (Breast Imaging Reporting and Data System) is used to determine the likelihood of a mass being cancerous. If a mammogram is given a zero, further imaging studies are used for characterization. A BI-RADS score of 4-5 denotes that a malignant is highly suspected and further diagnostic studies such as a biopsy is needed (Esserman & Joe, 2019). Part of the course of diagnosis in breast cancer is also to determine the stage of malignancy and the extent of the disease, such as metastasis.
Standard Treatment Plan
Treatments are individualized depending on the stage of progression of the disease and other factors such as risk factors for recurrence and if the patient has other comorbidities. Early stage breast cancer patients may undergo surgery to remove the mass (lumpectomy) or to remove the breast (mastectomy) depending on what option is right for them (Taghian, & Merajver, 2020). In addition, a patient may also be treated adjuvant therapy such as chemotherapy and radiation to resolve any undetected micrometastases that remain after surgery. Other forms of treatment include hormone therapy. If a tumor proves to be responsive to estrogen, then the estrogen hormone stimulation is removed. This is done by way of removal of the ovaries in premenopausal patients and by hormone blocking agents in post-menopausal women (Hubert & VanMeter, 2018).
Links to Routine Screening and Treatment
Breast self-examination is recommended for all women over the age of 20 and for men at high risk for breast cancer (see Surprise Nugget section for more information on male breast cancer). The U.S. Preventive Services Task force recommends biennial screening mammography for women ages 50-74 years, and earlier if at higher risk for breast cancer. All screening recommendations can be found at https://uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening. Additional screening tools such as step-by-step instructions on completing a breast self-examination can be found at https://www.breastcancer.org/symptoms/testing/types/self_exam. Routine visits to a primary care physician related to women’s health is also recommended for routine screening support and education.
The incidence of male breast cancer has increased 26% in the past 25 years (Gradishar & Ruddy, 2020). Male breast cancer is often linked with a family history in a first-degree relative and often presents in the same fashion as female breast cancer. Alterations in estrogen and androgen rations may also increase risk for male breast cancer. These alterations could result from hepatic dysfunction, obesity, thyroid disease, marijuana use, and inherited conditions such as Klinefelter syndrome. In Klinefelter syndrome, there is an inheritance of an additional X chromosome causing atrophic tested, gynecomastia, increased levels of follicle-stimulating and luteinizing hormones, and a decrease in testosterone. It is recommended that men with Klinefelter syndrome understand the affiliation and how to conduct self-examinations for breast cancer (Gradishar & Ruddy, 2020).