Sexuality and Reproductive Health

Female Menstrual Cycle

The normal menstrual cycle ranges from 21 to 42 days (mean 28 days). The duration of flow ranges from 2 to 8 days (mean 5 days). Blood loss per cycle ranges from 20-80 cc (mean 35 cc).


More info: differential diagnosis of amenorrhea


  • Excessive exercise
  • Weight changes (up or down)/ eating disorders
  • Stress/ chronic illness
  • Drugs/ medications
  • Familial causes (e.g., Kallmann's syndrome with anosmia and hypogonadism
  • Syndromes (e.g., Prader Willi)
  • Idiopathic


  • Tumor (e.g., prolactinoma)
  • Sheehan's syndrome (infarction of pituitary during childbirth)
  • Idiopathic


  • Thyroid dysfunction
  • Congenital Adrenal Hyperplasia
  • Hormone secreting tumors


  • Gonadal dysgenesis (e.g., Turner Syndrome)
  • Ovarian failure (autoimmune, radiation, chemotherapy)
  • Polycystic Ovary Syndrome (PCOS)


  • Müllerian aplasia (a.k.a., Mayer-Rokitansky-Küster-Hauser syndrome)
  • Pregnancy
  • Asherman's syndrome (uterine synechia)
  • Transverse vaginal septum
  • Imperforate hymen


  • Enzyme deficiencies (inability to make sex hormones)
  • Receptor defects (e.g., androgen insensitivity, 46 XY)

Primary amenorrhea is defined as:

  • no pubertal changes by 14 years of age (or the presence of stigmata of Turner syndrome at any age). This is really the definition of delayed puberty,
  • no menstrual bleeding by age 16,
  • no episode of menstrual bleeding despite having reached Sexual Maturity Rating 5 for at least one year, or
  • no menarche despite having started breast development 4 years previously.

Secondary amenorrhea is defined as no menses for 6 months or a period of time equal to 3 previous cycles, whichever is shorter, after previous uterine bleeding. If galactorrhea or hirsutism accompany missed menses, the cause should be investigated immediately without waiting for the individual to meet the strict criteria for amenorrhea.

Evaluation of amenorrhea

The history should include information on growth, pubertal development, previous menses, sexual activity, drug use and family history.

Physical examination should include general appearance, pubertal development, evidence of androgen excess (acne, hirsutism), dysmorphism, and testing for visual fields (pituitary tumor) and sense of smell (Kallmann's syndrome). The thyroid should be checked and the abdomen palpated for masses.

Clitoromegaly and imperforate hymen should be looked for on vulvar examination. A pelvic or a recto-abdominal exam may be performed to examine the uterus and adnexa.

Initial laboratory studies should include a pregnancy test along with thyroid studies, prolactin level, luteinizing hormone, and follicle stimulating hormone.

Abnormal Vaginal Bleeding

The most common cause of abnormal vaginal bleeding in girls is primary dysfunctional uterine bleeding. This is usually seen in association with an ovulatory cycles occurring in the first two years after menarche. The term "primary" indicates that no pathology is involved.

Other common causes of abnormal bleeding include sexually transmitted infections, use of hormonal contraceptives, and problems with pregnancy.

More Information: abnormal vaginal bleeding 

Complications of Pregnancy

  • Ectopic Pregnancy
  • Threatened or incomplete abortion
  • Miscarriage
  • Placental problems (e.g., placental abruption, placenta previa)

Local Pathology

  • Endometritis or cervicitis (sexually transmitted infection)
  • Vaginal or uterine polyp
  • Uterine myoma
  • Trauma
  • Foreign body (e.g., retained tampon, intrauterine device)
  • Ovarian problems (e.g., premature failure, Polycystic Ovary Syndrome)

Systemic Illness

  • Blood dyscrasias (e.g., Von Willebrand's disease, thrombocytopenia)
  • Connective tissue disease (systemic lupus erythematosus)
  • Hsepatic or renal disease
  • Leukemia and other malignancies
  • Thyroid disease
  • Adrenal disorders (e.g., congenital adrenal hyperplasia, Cushing syndrome)


  • Hormonal contraceptives
  • Seizure medications
  • Anticoagulants
  • Nonsteroidal anti-inflammatory drug (e.g., aspirin)

Hypothalamic-Pituitary Dysfunction*

  • Tumor (e.g., prolactinoma)
  • Stress
  • Weight changes/ eating disorders
  • Over exercise

* Many of the same things that cause amenorrhea (no bleeding) can cause dysfunctional bleeding when affecting the hypothalamus and pituitary. When the problem starts there is often dysfunctional or abnormal bleeding which then develops into amenorrhea.

Evaluation of abnormal vaginal bleeding. History and physical examination are similar to that for amenorrhea with the addition of clinical quantification of blood loss and inquiry about symptoms related to blood loss (e.g., fatigue, dizziness). Studies should include a complete blood ount and depending on the situation, a pregnancy test along with tests for gonorrhea and chlamydia. Other studies that may be considered include prolactin level, thyroid function, FSH/LH, BUN/creatinine, liver functions, and androgen levels.

Therapy. Treatment of abnormal vaginal bleeding is aimed at the underlying condition. In the case of primary dysfunctional uterine bleeding, treatment is determined by the severity of bleeding. This may range from reassurance to iron supplementation to the use of oral contraception.


Primary dysmenorrhea is recurrent crampy lower abdominal pain associated with menstruation. Other symptoms include nausea, headache, thigh pain, backache and diarrhea. The abdominal pain is due to prostaglandins causing contractions of the smooth muscle of the uterus.

Dysmenorrhea can also be due to endometriosis, pelvic inflammatory disease, congenital malformations of the reproductive tract, tumor, or a complication of pregnancy (e.g., ruptured ectopic). Pain preceding or extending past menses, pain on defecation and dyspareunia should cause concern.

In most patients, NSAIDs such as ibuprofen, naproxen, indomethocin, and mefenamic acid provide symptomatic relief. These medications are also inhibitors of prostaglandin synthesis, as is acetaminophen. Aspirin is not indicated as it is no better than placebo and it increases menstrual bleeding. Some patients may require oral contraceptives. Exercise also helps to relieve the pain.

Premenstrual Syndrome (PMS)

PMS refers to a constellation of symptoms that occur in the second half of the menstrual cycle and resolve with menstruation. Symptoms include fluid retention, bloating, breast tenderness, headaches, irritability, fatigue, anxiety, hostility, depression and/or a craving for sweets, salts or alcohol.

Treatment includes regular exercise, NSAIDs, hormonal birth control agents, and diet modifications such as low salt intake.