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New book presents medical side of menstrual disorders

Interpreting cycle disorders is critical to making early diagnoses of systemic diseases and abnormalities

From the April ACP Observer, copyright 2006 by the American College of Physicians.

By Tom Hartman

Although menstrual disorders may be very common, their health implications often go unrecognized by both women and their physicians.

Too many women will talk only with a gynecologist about menstrual symptoms and cycle changes, considering those to be "gynecologic" issues. But many menstrual irregularities can be traced to medical problems—and, if they remain unresolved, can profoundly affect women's health. Polycystic ovary syndrome, for example, presents with cycle irregularities and is found in as many as 10% of American women. It can lead not only to infertility, but also to increased risk for diabetes, cardiovascular disease and endometrial cancer.

To help internists treat the medical causes and implications of menstrual disorders, ACP this spring is issuing the latest title in its acclaimed Women's Health book series: "Menstrual Disorders." (See "Ordering 'Menstrual Disorders'".) One of the book's co-editors, internist Deborah B. Ehrenthal, FACP, assistant residency program director for the obstetrics and gynecology program at Christiana Care Health System in Wilmington, Del., discussed the new release:

On why the book was needed:

Primary care physicians and internists are not getting the information they need to adequately diagnose and treat these disorders.

While cycle changes or abnormalities can be due to a gynecologic problem, more often they are the gynecologic manifestation of a systemic disease process or abnormality—which primary care providers can best address. As primary care physicians, we need to be more proactive about taking a menstrual history because early diagnosis can be key.

On how medicine's approach to these disorders has evolved:

For one, we're increasingly recognizing the importance of chronic anovulation, which used to be called dysfunctional uterine bleeding or DUB. We now understand that it is critical to identify the underlying cause, not just create a normal menstrual cycle with hormones.

Another development is finding that unrecognized bleeding disorders are responsible for up to 20% of cases of abnormal uterine bleeding. That points to the need to evaluate for these disorders, especially for Von Willebrand's Disease, before choosing a surgical solution.

We also have new surgical methods for managing uterine bleeding and fibroids that do not involve hysterectomy. And we have new hormone delivery systems, including the levonorgestrel IUD and extended hormone regimens, to manage some menstrual disorders.

On how she became interested in the topic:

As an internist in a gynecology office, I always made sure I took a careful history—and was amazed at the number of women who had menstrual complaints. In essence, "Menstrual Disorders" is the book I wish I had as a reference to guide me through the evaluation and management of the disorders I encountered.

It is the first book that my co-editors and I are aware of that blends the fields of gynecology, adolescent medicine, internal medicine and other medical subspecialties into one comprehensive, integrated volume.

On how the book is tailored specifically to internists:

Internists' experience with gynecologic symptoms is variable. Textbooks in the field typically address menstrual symptoms superficially.

Our book covers common menstrual symptoms of irregular bleeding in adolescents, abnormal bleeding, amenorrhea, perimenopausal bleeding, dysmenorrhea and premenstrual syndrome.

We approach each disorder as an internist would, with detailed discussions about differential diagnosis and key elements in the history, physical exam and diagnostic testing. Each chapter addresses management options and when patients should be referred to a gynecologist, although most clinical problems are probably best managed in primary care.

The book also details menstrual, contraceptive and reproductive issues for women with chronic medical problems. These illnesses have a major impact on menstruation and fertility—and affect a growing number of patients being cared for by internists.

And the book includes chapters on caring for women with polycystic ovary syndrome and on the complex menstrual and contraceptive management of women with disabilities. One chapter guides clinicians though the evaluation and management of bleeding disorders, including von Willebrand's Disease. Finally, the book includes an overview of procedures used in managing abnormal uterine bleeding, with old and new treatment modalities including endometrial ablation and uterine artery embolization.

Tom Hartman is Editor of the ACP Books Program.

Ordering "Menstrual Disorders"

You can order "Menstrual Disorders," the latest in ACP's Women's Health Series, from the "Shop ACP" link on ACP Online or by calling Customer Service at 800-523-1546, ext. 2600, or 215-351-2600 (Monday-Friday, 9 a.m.-5 p.m. ET).

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