Why do most women visit the doctor’s office? #208/15

Q         From ages 12 to 50, what are the most common reasons why a woman makes a trip to the physician’s office?

A:        That’s an easy one!

Women go to the physician and nurse practioners because of menstrual cycle problems.Below is a case of a 14 year-old who has never had intercourse and who considered the use of contraceptives:

A 14 year-old rural Georgia teenager misses 2-3 days of school every month because of severe menstrual pain. She has never had intercourse.  The youth leader at her conservative church says she will give up her appointment with her gynecologist so that he could see and prescribe pills for the teenager to diminish the menstrual cramps and pain.

The girl’s father called his daughter both a “slut” and a “whore” for considering starting birth control pills. After 3 more cycles of more pain and missed school, the father changed his position.  She starts birth control pills and her pain resolves almost completely.

MENSTRUAL PAIN:

Menstrual cramps and pain are serious.

How common in 19 year-olds?  72% report painful periods, 15% had to limit daily activities, 8% missed school or work every cycle, 38.2% regularly used medical treatment [Fritz, Speroff, Clinical Gynecologic Endocrinology and Infertility. 8th ed. P.579, Walters Kluwer/Lippincott Williams & Wilkins, 2011, Oxford University Press, 1999]

Dr. Kate Miller (University of Pennsylvania) encourages women to recognize that “this monthly discomfort (cramps, fatigue, and irritability) is simply not obligatory”. [Karen Miller IN Conthinho EM, Seagal S.J. Is menstruation obsolete?] 

All these contraceptives definitely may help:  the Mirena IUD, birth control pills, rings, injections and the Nexplanon implant.  

  1. Menstrual cycle problems
    1. Heavy menstrual bleeding (HMB) is no longer solely defined by the amount of blood a woman looses (eg 80cc).  Heavy bleeding has happened “when a woman says it has happened”.  HMB affects 9-14% of women but closed to 30% of women consider their bleeding to be heavy [Nelson A. and Baldwin S. Menstrual Disorders IN Hatcher Contraceptive Technology 20th ed, 2011].  Because of missed work, women with HMB earn an average of $1,692 less annually than women with normal menses [Cate I., et.al., Obstet Gynecol, 2002].  Diseases that may cause HMB: fibroids (leiomyomas), adenomyosis, endometrial and uterine polyps, endometrial hyperplasia and cancer, and diseases of disordered homeostasis.  However, only about half of women with HMB have an anatomical pathology identified at hysterectomy. [Clark A., et.at., Br J Obetet Gynecol, 1995].
    2. Painful menses (Dysmenorrhea) includes both pain and cramping.  When taking a history ask women using both terms.  In one study of young women attending an FP clinic 72% reported having experienced dysmenorrhea; 15% the symptoms were severe enough to interfere with normal activities; 8% miss school or work everyday [more about this in Nelson A. and Baldwin S. Menstrual Disorders IN Hatcher Contraceptive Technology 20th ed. 2011].  Dysmenorrhea may be secondary to adenomyosis, pelvic adhesions, neoplasia and pelvic infections.
    3. Endometriosis is an important cause of severe dysmenorrhea.  It consists of endometrial glands and stroma outside the uterus.  Asymptomatic endometritis is present in 12 to 32% of reproductive age women with pain, in 9-50% of infertile women and in approximately 50% of teens with chronic pain [Fritz MA, Speroff L. Clinical Gynecologic Endochronology and Infertility 8th Ed 2011, p1223].

CONTRACEPTION: Treatments that diminish or eliminate menses often successfully reduce symptoms of dysmenorrhea caused by endometriosis.  The LNG IUD [Fidele L. et. Al., Fertil Steril 1997], Depo-Provera and Depo sub Q Provera 104 and combined pills taken cydicly or preferably continuously can all improve a women’s endometriosis.

    1. Premenstrual syndrome (PMS) See page 557 of the 20th Ed. of                     Contraceptive Technology to find the very complicated diagnostic criteria for premenstrual dysphoric disorders.

CONTRACEPTION: Contraceptives most likely to have a beneficial effect are those that supply ovulation and reduce the number of withdrawal bleeding episodes.  Extended cycle dosing of combined pills, vaginal contraceptive rings and Depo-Provera injections reduce the number of withdrawal bleeding episodes (and associated symptoms).  Combined pills taken 21/7, 21/7, 21/7 may decrease or increase PMS symptoms.  Randomized, placebo controlled, double blinded studies found that both mood disorders and physical complaints of PMDD will reduce by 50% in women on a 3mg drospirenone pill [Yonkers KA., Obstet Gynecol 2005].

Robert A. Hatcher MD, MPH

Emeritus Professor of Gynecology and Obstetrics

Emory University School of Medicine

Atlanta, GA

To learn more about the advantages and disadvantages of birth control pills, Mirena IUDs, rings and Depo-Provera injections, go to: www.managingcontraception.com.  You can order all of these books listed below from our website or by calling 404-875-5001. 

Key Words:  reasons, physician’s office visit, menstrual pain, cramps, heavy bleeding, missed work, school, fibroids, endometriosis, cancer, disorders, combined pills, rings, Mirena IUD, Depo-Provera injections, dysmenorrhea, activities, pelvic adhesions, pelvic infections, uterus, reproductive women, chronic pain, teens, contraception, premenstrual syndrome

References:

Fritz MA, Speroff L., Clinical Gynecologic Endocrinology and Infertility. 8th ed. P.579: Wolters Kluwer/Lippincott Williams & Wilkins, 2011]

Karen Miller IN Continho EM, Seagal S.J. Is Menstruation Obsolete?, Oxford University Press, 1999

Nelson A. and Baldwin S. Menstrual Disorders IN Hatcher Contraceptive Technology 20th ed, 2011

Cate I., et.al., Obstet Gynecol, 2002

Clark A., et.at., Br J Obetet Gynecol, 1995

Fritz MA, Speroff L. Clinical Gynecologic Endochronology and Infertility 8th Ed 2011, p1223

Fidele L. et. al., Fertil Steril 1997

Yonkers KA., Obstet Gynecol 2005

Current Books:

Contraceptive Technology 20th edition

Managing Contraception 2015-2016 edition

Choices 2014 edition