1. The document discusses the menstrual cycle and abnormalities including dysmenorrhea. It describes the four phases of the menstrual cycle and hormonal control. 2. Abnormalities like primary and secondary dysmenorrhea are explained. Physical therapy modalities for primary dysmenorrhea including TENS, pulsed magnetic field therapy, and low level laser therapy are outlined. 3. Studies show these physical therapy modalities can help relieve pain and symptoms of primary dysmenorrhea.

2. MOHAMED GAMALABOUELYAZEED
ASSISTANT LECTURER OF PHYSICAL
THERAPY FOR WOMEN’S HEALTH
SOUTH VALLEY UNIVERSITY

3. Menstrual Cycle
and Physical
Therapy Role for
Its
Abnormalities

4. *The menstrual cycle starts on the first day of the menstrual
period and ends with the start of the following period.
*It is made-up of four phases during which hormones change to
prepare women for pregnancy each month.
*The menstrual cycle is the
regular natural change that occurs
in the female reproductive system
(specifically the uterus and ovaries)
that makes pregnancy possible.
*The cycle is required for the
production of oocytes, and for the
preparation of the uterus for pregnancy.
*The menstrual cycle occurs due to the
rise and fall of estrogen.

5. *The first period usually begins between twelve and fifteen years of
age, a point in time known as menarche.
*They may occasionally start as early as eight, and this onset may still
be normal.
*Normal characteristics of menstrual cycle:
-The typical length of time between the first day of one period and the
first day of the next is 21 to 35 days in adult women (an average of
28 days).
-Average duration of menstruation is 3-5 days.
-Average blood loss is 30-50 ml./cycle and any amount greater than
80 ml./cycle is considered abnormal .
-Average follicular phase length is 10-16 days.
-Average luteal phase length is 12-14 days.

6. At the fourth month of fetal development, the ovaries contain
some 6 –7 million oocytes surrounded by a layer of flat granulosa
cells to form the primordial follicle pool.
Due to a rapid loss of the great majority of the primordial follicles
via apoptosis in the second half of fetal life,
at birth only 1.5–2 million primordial follicles remain after birth.
At menarche at least 300,000 - 400,000 primordial follicles and
each ovary contains about 200,000 primordial follicles.
Every month about 20-50 follicles are prepared for ovulation and
only one follicle will be mature graafian follicle ( Ready for
ovulation).
The ovarian follicles become gradually exhausted until they become
depleted by the time of menopause.

8. *Primordial Follicle:
An ovarian follicle progresses through several distinct
phases before it releases its ovum. During the first five
months of development, a finite number of primordial
follicles form in the fetal ovary. These follicles consist of a central
oocyte surrounded by a single layer of flattened follicular cells
(Granuolsa cells).and the diameter of primary oocyte is about 25 μm.
*Primary Follicle:
-Early unilaminar primary follicle that consists of
a central oocyte surrounded by a single layer of
follicular cells which have become cuboidal. The zona
pellucida is a thin band of glycoproteins that separates the oocyte and
follicular cells. and the diameter of primary oocyte is larger (40 μm).
Follicular development

9. -Late multilaminar primary follicle that consists
of a central oocyte surrounded by follicular cells form a
stratified epithelium around the oocyte. The zona
pellucida is a thick band of glycoproteins. and the
diameter of central oocyte is larger (50 μm). Theca
folliculi, a layer located outside the basement membrane
of the follicular cells, is formed.
*Secondary Follicle:
appearance of a follicular antrum within the
granulosa layer. The antrum contains fluid which
is rich in hyaluronan and proteoglycans.
There is an increase in layers of granulosa cells, the
thicker zone pellucida, and larger oocyte (120μm).
The theca folliculi differentiates into: secretory (Theca
interna) and non secretory (Theca externa).

10. *Mature ( Graafian) Follicle:
-The follicle that will rupture, ovulating a secondary oocyte. Present
only during the day preceding ovulation.
-The diameter of the oocyte is larger
(150 μm).
-Increase follicular liquid that greatly
increases antral and follicle size.
-The cumulus oophorus is a hillock
of granulosa cells in which the primary
oocyte is embedded.
-The innermost layer of cumulus cells, immediately surrounding the
oocyte, forms the corona radiata.

11. -The theca externa is characterized by the presence of smooth
muscle cells, which are innervated by autonomic nerves. there is
evidence that it contracts during ovulation and atresia.
-The theca interna is richly vascularized and serves to deliver
hormones (e.g. FSH, LH), nutrient molecules, vitamins, and
cofactors required for the growth and differentiation of the oocyte
and granulosa cells.

13. Hormonal control of
menstrual cycle
The menstrual cycle is complex and is
controlled by many different glands and
the hormones that these glands produce.
A brain structure called the hypothalamus
causes the nearby pituitary gland to
produce certain chemicals (FSH & LH) ,
which prompt the ovaries to produce the
sex hormones estrogen and progesterone.
The menstrual cycle is a biofeedback
system, which means each structure and
gland is affected by the activity of the
others.

14. Hormonal feedback
loop:
*The hypothalamus releases
gonadotropin
releasing hormone
(GnRH) → stimulates anterior
pituitary gland to release follicle-
stimulating hormone (FSH)
*FSH recruits a group
of maturing follicles in
the ovary → growing follicles
produce estradiol and inhibin A at
increasing levels → negative
feedback to the pituitary gland →
inhibits the release of FSH

15. *One follicle becomes the dominant follicle and estradiol levels peak
at the day before the luteinizing hormone (LH) surge → high levels
of estradiol induce positive feedback to pituitary gland → LH levels
increase.
*LH surge induces ovulation →
the mature oocyte is released from
the dominant follicle and the
corpus luteum produces
progesterone → increase in
Progesterone inhibits LH surge.
*Falling LH levels cause resolution
of the corpus luteum → fall in
progesterone and estradiol levels.

16. *The hormonal feedback loop is also influenced by
other hormones (e.g., prolactin) and neurotransmitters (e.g., opioids,
acetylcholine and noradrenaline).

18. *The four phases of the menstrual cycle:
1-menstruation
2-the follicular phase
3-ovulation
4-the luteal phase.
1-Menstruation
*Menstruation is the elimination of the thickened lining of the uterus
(endometrium) from the body through the vagina.
*Menstrual fluid contains blood, cells from the lining of the uterus
(endometrial cells) and mucus. The average length of a period is between
3-7 days.
*Desquamation: Absence of a pregnancy → resolution of corpus
luteum → progesterone and estrogen concentration decreases → induces
vasospasms in the uterine spiral arteries, ischemia, and sloughing off
of the functional layer (Superficial layer) of the endometrium.

19. 2-Follicular phase
*The follicular phase starts on the first day of menstruation and ends
with ovulation.
*Prompted by the hypothalamus, the pituitary gland releases follicle
stimulating hormone (FSH).
*Each follicle houses an immature egg. Usually, only one follicle will
mature into an egg, while the others develop atresia. This can occur
around day 10 of a 28-day cycle.
*The growth of the follicles stimulates the lining of the uterus to thicken
in preparation for possible pregnancy.
*Proliferation of endometrial epithelial cells, Endometrial glands are
straight, tubular, and, Stromal cells start to divide, enlarge, and
accumulate glycogen. Uterine spiral arteries start to regenerate.

20. 3-Ovulation
*Ovulation is the release of a mature egg from the surface of the ovary.
This usually occurs mid-cycle, around two weeks or so before
menstruation starts.
*During the follicular phase, the developing follicle causes a rise in the
level of estrogen. The hypothalamus in the brain recognizes these rising
levels and releases a chemical called gonadotropin-releasing hormone
(GnRH). This hormone prompts the pituitary gland to produce raised
levels of luteinizing hormone (LH) and FSH.
*Ovulation is triggered within 16-32 hours after the high levels of LH
( LH surge). The egg is funneled into the fallopian tube and toward the
uterus by peristaltic movements of small, hair-like
projections(Fimbriae).
*The life span of the typical egg is only around 24 hours. Unless it is

21. 4-Luteal phase
*During ovulation, the egg bursts from its follicle, but the ruptured
follicle still inside the ovary forming a corpus luteum For two weeks.
*This structure starts releasing progesterone, relaxin and small amounts
of estrogen. This combination of hormones maintains the thickened
lining of the uterus, waiting for a fertilized egg to implant.
*If fertilization occurs, (Corpus luteum of pregnancy for 3-4 months).
produces the hormones that are necessary to maintain pregnancy(good
implantation) by raised levels of progesterone→ Increased endometrial
gland tortuosity, Glycogen-rich secretions, Edematous stromal cells and
Uterine spiral arteries extend the full length of the endometrium.
*If pregnancy does not occur, the corpus luteum degenerates after 10-14
days and converted into a corpus albicans. sharp drop in progesterone
&E2 levels stimulates menstruation. The cycle then repeats.

24. The four major natural
estrogen types in women:
are estrone (E1), estradiol (E2),
estriol (E3), and estetrol (E4).
Estradiol is the predominant estrogen
during reproductive years.
During menopause, Estrone is the
predominant circulating estrogen.
During pregnancy Estriol is the
predominant circulating estrogen.
Estetrol is produced only during
pregnancy. It is produced exclusively
by the fetal liver.

25. Abnormalities of menstrual cycle:
*Dysmenorrhea
*Premenstrual syndrome
*Abnormal uterine bleeding
*Amenorrhea
1-Dysmenorrhea:
also known as painful periods or menstrual cramps, is pain and
cramping during menstruation that interferes with normal activities
and require therapeutic approaches to control the symptoms.
Pain may range from mild discomfort to sever pain that causes some
patients to be bedridden for 1-3 days every month.
Dysmenorrhea affects 40-90% of women during their reproductive
age . About 50% of women will suffer significant pain.

26. (A)Primary dysmenorrhea
Definition: recurrent lower abdominal pain shortly before or during
menstruation (in the absence of pathologic findings that could account
for those symptoms) and it is common in young women < 20 years old.
Epidemiology: prevalence up to 90%
(most common gynecologic condition)
Etiology: unknown; association with some risk factors (e.g.,
early menarche, nulliparity, smoking, obesity, positive family history)
Pathophysiology: It is almost associated with ovulatory cycles.
Increased endometrial prostaglandin (PGF2 alpha)
production → vasoconstriction/ischemia and stronger, sustained uterine
contractions.

27. Clinical features:
-Spasmodic, crampy pain in the lower abdominal and/or pelvic
midline (often radiating to the back or thighs)
-Usually occurs during the first 1–3 days of menstruation
-Headaches, diarrhea, fatigue and nausea are common symptoms.
Diagnosis: Primary dysmenorrhea is a diagnosis of exclusion;
conditions causing secondary dysmenorrhea must be ruled out.
Treatment:
-Symptomatic treatment: pain relief
(e.g., NSAIDs), topical application
of moist heat, TENS, LLLT, IF,
PSWD, Relaxation training&KT.
-Hormonal contraceptives (e.g., combined oral contraceptive
pills, IUD with progestogen)

28. (B)Secondary dysmenorrhea
Definition: recurrent lower abdominal pain shortly before or
during menstruation that is due to an underlying condition and it is
common in middle aged women (30-35 years old).
and it may occur in both ovulatory and anovulatory cycles.
Possible causes:
-Endometriosis
-Pelvic inflammatory disease (PID)
-Uterine leiomyoma (Fibroids)
-Adenomyosis
-Polycystic ovary
-Pelvic adhesions
-Pelvic congestion syndrome
-Intrauterine device (IUD)
-Cervical stenosis

29. Diagnosis and Clinical features:
-Colicky suprapubic or dull aching pain commonly associated
with low backache that usually occurs after several years of
relatively painless menstruation.
-Usually pain starts few days before menses and gradually
decreases by onset of menses.
Treatment:
-Pain relief: Such as- NSAIDs and TENS
-Depend on the primary cause:
*Hormonal treatment → COCP, GNRH agonist
(as in endometriosis)
*Surgical treatment → Myomectomy, Hysterectomy
(as in fibroids)
*Physical therapy → US, IF, PSWD, Therapeutic exercises
(as in endometriosis)

30. *Physical therapy for Primary Dysmenorrhea:
1-TENS:
Electrode placement: -Lower abdomen
-Lower back
-Acupuncture points
Frequency: (High frequency TENS 50-120 HZ)
Pulse width: 100 microseconds
Intensity: according to patient’s tolerance
Duration: 20-60 min. and 20–30 min. is probably
the minimum effective time.
Mechanism: Gate control theory

31. *High-frequency TENS was found to be effective for the treatment of
dysmenorrhea by a number of small trials But
There is insufficient evidence to determine the effectiveness of low-
frequency TENS in reducing dysmenorrhea (Proctor et al., 2010) in a
Cochrane review from seven studies.
*TENS method seems to be effective in managing primary
dysmenorrhea. It is free from the adverse effects of analgesics, gives
immediate pain relief and had no adverse effects (Parisa and Saied,
2013).

32. *TENS was efficacious and safe in relieving pain in participants with
Primary dysmenorrhea (Bai et al., 2017).
*In Jan 2020 a review that published in International Journal of
Women's Health concluded that: Several studies have investigated the
effectiveness of TENS in reducing pain, decreasing the use of analgesics,
and improving the quality of life in primary dysmenorrhea patients.
These studies have some limitations in methodological quality and
therapeutic validation. However, the overall positive effects of TENS in
primary dysmenorrhea encountered in all prior studies indicated its
potential value (Gabyzon and Kalichman, 2020).

33. 2-Pulsed Magnetic Field Therapy(PMFT):
Electrode placement: - PEMF
electrodes was applied on the
suprapubic region and the other
electrode on the lower lumbar region
from (T10-L1) or (L4 to S3).
Frequency: 50 Hz
Duration: 30-60 min.
Intensity: 60 Gauss
*PEMF was administered before the
onset of menstrual flow, then at the first
and second day of menstruation for
three consecutive cycles.

34. *PEMF was used to treat soft tissue inflammation through the
magnetic field action by altering the cell membrane potential and
influencing ionic fluxes. Inflammatory edema and hematoma
formation were decreased by PEMF treatment and microcirculation
was significantly enhanced.
*Pulsed electromagnetic field was effective than diclofenac drugs in
relieving pain and associated symptoms with primary dysmenorrhea
(Mohammed et al., 2017) .
*Pulsed electromagnetic waves and LLLT are effective methods in
the treatment of primary dysmenorrhea, with better effects of pulsed
electromagnetic waves than LLLT (Mohamed, 2017).
*PEMF is effective in improving primary dysmenorrhea pain and
menstrual distress score (Abd El Aziz et al., 2018).

35. 3-Low Level Laser Therapy(LLLT):
*LLLT has been shown to cause : provocation of ATP
synthesis, induction of anti-inflammatory responses, and
production of physiologically active substances, such as
nitric oxide (NO) →Vasodilator, cyclic adenosine
monophosphate (cAMP) →uterine smooth muscle
relaxant and endorphins.
*GaAlAs LASER (904nm) may be applied (L4-S3)
3 points paravertebral and 3 points on suprapubic
region for 6o sec. for each points. Just before
menstruation and through the next 2 days.
*LLLT on acupuncture points CV4(A) and CV6 (B) for
20 min a day over a period of 3-7 days prior to the
expected onset of menstruation was an effective and
safe treatment for controlling pain in patients with
primary dysmenorrhea. (Hong et al., 2016).

36. 4-Interferential Current(IF):
Electrode placement: - Quadripolar current vector technique was used
in the lumbar region with the electrodes positioned between T12 and S2,
3 cm lateral of the vertebral column, the two channels were crossed.
Frequency: (Carrier freq. 4 KHz, Beat freq. 90-130 Hz)
Intensity: according to patient’s tolerance
Duration: 20-30 min.
*Both TENS and IFT are equally effective in relief
of pain in primary dysmenorrhea. However, tolerance
to IFT currents is better among young women as they
are medium frequency currents (Revadhar and Bhojwani, 2019).
*The interferential current in the quadrilateral form with treatment for
3 days in two menstrual cycles was shown to be effective in reducing
pain in young patients with primary dysmenorrhea (Okuyama et al.,
2019).

37. *This systematic review and meta-analysis suggested that heat
therapy was associated with a decrease in menstrual pain in women
with primary dysmenorrhea. These results from 6 Randomized studies
are consistent with the recommendation of local heat as a
complementary treatment for dysmenorrhea (Jo and Lee, 2018).
Jo J, Lee SH. (2018): Heat therapy for primary dysmenorrhea: A
systematic review and meta-analysis of its effects on pain relief and
quality of life. Sci Rep. 8(1):16252.
5-Heat Therapy:

38. *The core strengthening exercises were significantly effective in
reducing the quality of pain and improving the quality of life in females
suffering from primary dysmenorrhea (Berde et al., 2019).
*The study concluded that, pelvic rocking exercise can be used to
reduce dysmenorrhea by strengthening the abdominal muscles and
smoothing the blood circulation and it was effective in reduction of
dysmenorrhea among adolescent girls (Nizy and Rajitha, 2019).
*The program featured14 stabilization exercises that focused on the
transverse abdominal muscles, the lumbar multifidus, pelvic floor
muscles, and the hip muscles, which were practiced using a Swiss ball.
The experimental group performed 8 weeks of core stability exercise (3
sessions/week, 45-60 min/session). Conclusion: Core stability exercises
may be effective in reducing pain intensity, pain duration, and consumed
painkillers in adult females complaining of primary dysmenorrhea
(Shahrjerdi et al., Jan.2020).
6-Core stability exercises:

39. Core stability

40. 7-Spinal mobilization & manipulation techniques:
*Maitland’s Spinal mobilization from T10 to L1 vertebrae. A
Posterio-Anterior glide grade 1 and grade 2 will be given from T10
to L1 vertebrae. In Prone lying a pillow was given under the abdomen
to make the patient more comfortable. Spinal mobilization techniques
were applied for each vertebral level. Both grade 1 and grade 2 was
given for 2-3 per second for 30 sec. Conclusion: mobilization is
effective in reducing pain among adolescent girls who suffer from
primary dysmenorrhea (Mistry et al., 2015).

41. *This randomized pilot study suggests that spinal manipulation
treatment (SMT) may be an effective and safe non pharmacological
alternative for relieving the pain and distress of primary dysmenorrhea
(Kokjohn et al., 1992).
*Participants received either a bilateral general pelvic manipulation
(GPM) technique (a semi-direct high-velocity, low-amplitude
technique applied to the fifth lumbar vertebra over the first sacral
vertebra and the sacroiliac joint [SIJ] with the participant in a lateral
position) . a significant decrease in low back pelvic pain and a
significant increase in PPTs of the left and right SIJs were noted and
serotonin plasma level within the experimental group after
intervention (Molins-Cubero et al., 2014).

42. 8-Aerobic exercises:
*The findings of the present study showed that 12-week regular aquatic
exercises (exercises were conducted with 60-80% of maximum heart
rate) with a regimen10 minutes of warming up in form of walking and
running in water, 40-45 minutes of aerobic, endurance, flexibility,
power, coordination, speed and agility in addition to other specific
exercises for abdominal and pelvic muscles and thighs. are effective on
decrease of the severity of the symptoms of primary dysmenorrhea
(Rezvani et al., 2013).
*The results of this study showed that performing
aerobic exercise (The exercise protocol included
aerobic exercise, which performed the intervention
group for at least 8weeks, three times a week, and
each time for 30 min.) can improve primary
dysmenorrhea. Therefore, aerobic exercise can be
used to treat primary dysmenorrhea (Dehnavi et al., 2018).

43. *Medical taping concept (MTC) seems to be a complementary effective
non-pharmacological treatment, which is simple, comfortable and self-
applicable in primary dysmenorrhea. This Kinesio taping technique
(Space correction technique 25% tension) reduced abdominal and leg
pain when the participant was not taking medication (two hours after
start of pain) and medication intake was also reduced (between two hours
and end of menstrual cycle) (Tomás-Rodríguez et al., 2015).
*Both kinesio taping and lifestyle changes can be
used to improve quality of life and body awareness
& to decrease pain level in primary dysmenorrhea (Doğan et al., 2020).
*KT application applied on the sacral and suprapubic regions with the
ligament technique seems to be an effective method in decreasing pain,
anxiety level, and some menstrual complaints in women with primary
dysmenorrhea (Celenay et al., Mar.2020).
9-Kinesio taping :

44. 10-Relaxation training:
*Relaxation techniques (progressive muscle relaxation) were
effective in treating both spasmodic and congestive dysmenorrhea,
however effectiveness observed in congestive cases was less than
that seen spasmodic cases (Kamali et al., 2002).
*Mitchell's simple physiological relaxation
technique for 30 minute/session, twice daily, 3 times/ week for
4 weeks which is based on physiological principle of reciprocal
inhibition and involves diaphragmatic breathing showed highly
significant reductions in pain intensity, pulse rate, respiratory rate
.It was found to be an effective, non invasive, safe, cheap, easy to
perform and successful treatment method in reducing pain and
tension of primary dysmenorrhea (El Kosery et al., 2006).

45. Definition: Syndrome that describe a group of physical and/or
emotional changes that constantly occur and recur un the luteal phase
of successive cycles. Changes should be sever enough to interfere with
regular life style to be classified as premenstrual syndrome (PMS).
Epidemiology: occurs in ∼ 5–10% of women
Clinical features:
-The highest incidence of PMS occurs in the late 20’s and early 30’s.
-Onset of symptoms should occur in the two weeks before
menstruation (Luteal phase) . With at least a 7 days symptoms free
interval in the first half of menstrual cycle.
- Headache, back pain, abdominal pain, nausea, breast tenderness,
weight gain, Tendency to edema formation, mood swings,
depression and anxiety.
2-Premenstrual syndrome (PMS):

46. Causes:-Not completely understood.
-May be due to interaction between serotonin and ovarian steroids.
-More pronounced in genetically & psychologically susceptible women.
Diagnosis:
-Diagnosis is based on history and self-assessment
-Preexisting endocrine (e.g., thyroid disorders) and psychiatric
(e.g., major depressive disorder) conditions should be ruled out.
Treatment:
-Selective Serotonin Reuptake Inhibitors (SSRIs): are effective in
treating physical and mood symptoms in women with sever PMS.
-Lifestyle changes (e.g., exercise, healthy diet, avoiding triggers like
caffeine, smoking or alcohol).
-Calcium 600mg,Vit D 800IU & Magnesium may improve PMS.
-NSAIDs and Oral contraceptives

47. *Physical therapy for Premenstrual syndrome:
*Overall, the findings showed that 8 weeks of aerobic exercise for 8
weeks, three sessions per week for 60 min. (60-80% maximum heart
rate) and This exercise was performed between the two menstrual
cycles was effective in reducing the symptoms of PMS and can be used
as a treatment (Samadi et al., 2013).
*It was found that diet and aerobic exercise for
12 weeks three sessions per week for 30 min. were
effective in reducing the symptoms of premenstrual
syndrome and dysmenorrhea intensity in female students with
premenstrual syndrome (Yilmaz-Akyuz and Aydin-Kartal, 2019).
*Kinesio taping is an easy, non-drug intervention for female college
students with premenstrual syndrome (Choi, 2017).

48. *Abnormal uterine bleeding is defined as menstrual bleeding that is
abnormal and/or irregular in frequency, duration, and/or intensity. It
may or may not be accompanied by dysmenorrhea.
Causes of AUB:
1- Pregnancy complications: as in abortion and ectopic pregnancy.
2-Benign uterine disorders: as in fibroids, adenomyosis , endometritis.
3-Gynaecological malignancies: as in endometrium, cervix and
ovarian cancers.
4-Systemic diseases: as in
-Coagulation disorders: Von willebrand disease or hemophilia
-Thyroid disorders: sever hypothyroidism or sever hyperthyroidism
-Liver diseases: sever hepatitis
5-Iatrogenic causes: as in Intra uterine Contraceptive Device and
anticoagulant drugs as heparin.
6-Dysfunctional Uterine Bleeding (DUB): bleeding without a
definitive cause (DUB → 60% of AUB).
3-Abnormal uterine bleeding:

49. *Patterns of abnormal uterine bleeding:
Polymenorrhea: Too frequent menstrual cycles that occur in < 21 days.
Oligomenorrhea: Infrequent menstrual cycles that occur in > 35 days.
Hypomenorrhea: scanty menstrual bleeding.
Menorrhagia: excessive menstrual bleeding.
Metrorrhagia: significant intermenstrual bleeding.
Menometrorrhagia: heavy bleeding during menstruation and
intermenstruation.
Postmenopausal bleeding: Any bleeding that occurs more than one
year after the last normal menstrual period at menopause.

50. 4-Amenorrhea:
*Primary amenorrhea:
absence of menses (onset of menarche) at the age of 15 or older.
*Secondary amenorrhea: absence of menses for more than 3
months (in women with previously regular cycles) or 6 months (in
women with previously irregular cycles).
Etiology:
-Physiological amenorrhea → as before puberty, after
menopause, during lactation and during pregnancy.
-Pathological amenorrhea →
1-Outflow Tract Disorders: as in imperforate hymen
2-Uterine developmental abnormalities: as in complete or partial
mullerian agenesis and asherman’s syndrome.

51. 3-Ovaian disorders: as in Turner syndrome and premature ovarian
failure.
4-Pituitary gland disorders: as in pituitary insufficiency
5-Hypothalamic and CNS disorders: as in congenital GnRH
deficiency, rapid weight loss, excessive exercises and drug-induced
amenorrhea (GnRH agonist, Progestins, COCPs and some anti
depressants).
6-Endocrinal disorders: as in hypothyroidism and Cushing syndrome.

52. 1) low energy availability: +/- disordered eating (anorexia nervosa).
2) menstrual dysfunction: (Oligomenorrhea or Secondary amenorrhea).
3) low bone density: due to reduced levels of both estrogen (E2
decreases osteoclasts activity )and progesterone(PRG increase
osteoblasts activity) → Osteopenia ,Osteoporosis and stress fractures).
Pathophysiology: decreased energy
availability → body regulates reproductive
potential down by decreasing GnRH
release from the hypothalamus → decreased
secretion of FSH and LH → anovulation and
secondary amenorrhea → infertility.
Treatment: Lifestyle changes → reduce stress, improve nutrition,
increase body weight BMI > 19 kg/m2.
*Female athlete triad is a medical condition
observed in physically overactive females involving three
components: