Polymenorrhea

Summary

Polymenorrhea is a menstrual disorder characterized by abnormally frequent menstrual cycles with intervals of less than 21 days between periods. While often benign and self-limiting, particularly in adolescents and perimenopausal women, polymenorrhea can indicate underlying endocrine dysfunction, structural pathology, or hormonal imbalances. Common causes include anovulatory cycles, luteal phase defects, thyroid disorders, and hyperprolactinemia. The condition may lead to significant quality of life impairment and iron deficiency anemia due to frequent blood loss. Diagnosis involves a thorough menstrual history, exclusion of pregnancy and systemic disorders, hormonal evaluation, and imaging when indicated. Management focuses on cycle regulation through hormonal therapy, treatment of underlying conditions, and prevention of anemia-related complications. Understanding polymenorrhea is essential for proper evaluation of menstrual disorders and providing appropriate counseling to patients.

Definition

• Polymenorrhea is defined as abnormally frequent menstrual cycles with intervals of less than 21 days between the first day of one period and the first day of the next
• Normal menstrual cycle interval: 21-35 days (average 28 days)
• The shortened cycle can result from:
  • Shortened proliferative (follicular) phase
  • Shortened secretory (luteal) phase
  • Both phases shortened
• Must be distinguished from:
  • Metrorrhagia: Irregular bleeding between periods
  • Menorrhagia: Heavy menstrual bleeding with normal cycle length
  • Menometrorrhagia: Heavy and irregular bleeding

Etiology

• Short proliferative phase: Early maturation of Graafian follicles due to pituitary hyperstimulation.
• Short secretory phase: Early degeneration of the corpus luteum, often associated with hypothyroidism or ovarian congestion.
• Dysfunctional polymenorrhea: Common shortly after menarche or during the perimenopausal period due to hormonal instability.

Clinical Features

Menstrual History

• Frequency: Menstrual cycles occurring at intervals of <21 days
• Duration: Usually normal (3-7 days per period)
• Amount: Typically normal volume per period, but cumulative blood loss is increased
• Pattern: May be regular (consistent short intervals) or irregular

Associated Symptoms

• Symptoms of anemia (if prolonged):
  • Fatigue and weakness
  • Pallor
  • Dizziness or lightheadedness
  • Shortness of breath with exertion
  • Palpitations
• Impact on quality of life:
  • Interference with daily activities
  • Need for frequent menstrual hygiene management
  • Anxiety about unpredictable bleeding
  • Sexual dysfunction
• Symptoms suggesting underlying causes:
  • Hypothyroidism: Weight gain, cold intolerance, constipation, dry skin
  • Hyperprolactinemia: Galactorrhea, headaches, visual disturbances
  • PCOS: Hirsutism, acne, obesity
  • Pelvic pathology: Pelvic pain, dysmenorrhea, dyspareunia

Diagnosis

Initial Evaluation

• Detailed menstrual history
• Family history: Bleeding disorders, thyroid disease, early menopause

Laboratory Investigations

• First-line tests:
  • β-hCG (pregnancy test): Always rule out pregnancy first دائماً استثني الحمل أولاً
  • Complete blood count (CBC): Assess for anemia, rule out thrombocytopenia
  • TSH (thyroid-stimulating hormone): Screen for thyroid dysfunction
  • Prolactin level: If galactorrhea or other symptoms suggest hyperprolactinemia
• Additional hormonal evaluation (if indicated):
  • FSH and LH
  • Day 21 progesterone
  • Androgens (testosterone, DHEA-S)
• Coagulation studies (if indicated):
  
  • Consider if heavy bleeding or family history of bleeding disorders

Imaging Studies

• Transvaginal ultrasound (TVUS):
• Saline infusion sonography (SIS): Better visualization of endometrial cavity if polyps or submucous fibroids suspected
• MRI pelvis: If ultrasound findings are equivocal or surgical planning needed

Endometrial Sampling

• Endometrial biopsy:
  • Not routinely indicated in polymenorrhea
  • Consider if:
    • Age >35-40 years with new-onset polymenorrhea
    • Risk factors for endometrial hyperplasia or cancer
    • Abnormal ultrasound findings
    • Failed medical management
• Hysteroscopy with biopsy:
  • Gold standard for evaluating intrauterine pathology
  • Allows direct visualization and targeted biopsy
  • Can be therapeutic (polyp removal)

Management

• Hormonal regulation: Progesterone supplementation during the second half of the cycle (from day 15) or combined oral contraceptives (COCs) for 21 days each month to normalize cycle length.
• Address underlying causes: Treat hypothyroidism if present.
• Supportive care: Manage associated anemia with iron supplementation and dietary optimization.