Ovarian problems, such as polycystic ovarian cysts syndromes. My treatment for that, I offer the patient a couple of choices. One is to withdraw menses every three months or so with Provera 10 mg for ten days, or put them on birth control pills to protect their hypothalamic pituitary axis and protect their endometrium from over-stimulation.
Renal blastomas, granulosa and thecal cell tumors and hilus cell tumors are difficult or may be very difficult to diagnose, but can cause bleeding. Chronic pelvic inflammatory disease - because of the vasculitis in the endometrium and also in the region of the ovaries - will cause bleeding. Endometriosis can be found almost anywhere and can interfere with the normal function of the endometrium and may cause abnormal bleeding just by having endometrial implants in the vagina. I’ve diagnosed several patients by seeing something that didn’t look normal and just biopsying it. Comes back as endometriosis.
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Then premature menopause, which is menopause that occurs before the age of 45, can cause you to have anovulation and menstrual irregularities. Drugs that will affect your menstrual cycles: just about everything. Morphine, reserpine, phenothiazines, MAO inhibitors, anticholinergics, and then any steroid preparations you give, such as progesterones: Norplant, Depo-Provera are known to create a lot of problems with irregular spotting and bleeding. Some patients are placed on testosterones for libido. Adrenal androgens can be produced. Estrogens can be produced. The patients may be getting exogenous estrogens that you don’t know about. One of the great places that they find them now are in these health food stores in the malls. They can actually get phyto-estrogen’s and buy estrogen-containing products and take them without anybody monitoring this. The west coast, a lot of patients are having menstrual irregularities and problems from exogenous estrogens from eating tofu. So that’s another source. So you have to investigate dietary sources if you suspect that this patient is getting exogenous estrogens or something. And oral contraceptives can create menstrual problems as we all know and have experienced.
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Stress, emotional stress, excessive exercise, things like a change in habits - even as simple as flying from New York to Los Angeles, spending a couple of days in Los Angeles, back to New York - can throw off ovulation and create menstrual irregularities. The morbidly obese patient can produce too much exogenous estrone where the fat tissue is changing hormones into estrone, creates an endometrial hyperplasia and bleeding. We discussed anorexia nervosa and malabsorption syndrome. Not so much nutritional, but let’s talk about exercise for a minute. Patients who excessively exercise burn up their steroid hormones and will have menstrual problems. You might see this in some of the patients on oral contraceptives too. I have one young lady that I treat with oral contraceptives because of her thrombocytopenia, to control her menses. She was doing jut beautifully on her oral contraceptives and then in October called up. Needed an appointment because she was not spotting and bleeding and so forth. So she came in to see me and everything was normal and I was interviewing here - I interview my patients as I’m seeing them - and I said, “Well, are you doing anything different?” She said, “Oh, no. I’m doing all the same stuff.” I said, “Okay, well you’re in school now?” “Oh, yes.” “Well, are you involved in any sports?” “Oh, yes. I’m cross-country running now.” That was enough, just enough, to burn up her steroid hormones enough to give her menstrual irregularities. So in the younger patient they may think that this is completely normal to go out and start doing something as in sports and don’t effect it to affect hormonal therapy or replacement or something like that. So if it will happen to that patients being treated with oral contraceptives are on pharmacologic and not physiologic doses, if she’s a young woman on her own cycling and not on oral contraceptives and starts some strenuous physical program, she may have trouble with bleeding
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