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The syndrome of the unexplained delayed menstrual period
CURRENT
OPINION
Pertinent comments
The syndrome of the unexplained delayed menstrual N.
SOFERMAN,
M.
HAIMOV,
Tel-Aviv,
period M.D. M.D.
Israel
F u N c T I o N A L menstrual disorders of psychogenic etiology are well known. The purpose of this paper is to present a group of cases in which a specific type of menstrual disorder is seen, closely associated with the very beginning of sexual life, or a sudden change in its pattern. The clinical picture which is well defined, bears great resemblance to some pathological varieties of early pregnancy, so its classification as a separate nosologic entity seems desirable. We have already presented some of these cases in a preliminary report.’ Clinical
tion. Part of these patients also have some of the subjective symptoms of pregnancy such as nausea, vertigo, breast engorgement, etc. In others an unusual pain may be present, concentrated principally in the lower abdomen. They all have some of the following additional characteristic features in common : 1. The disorder follows beginning of sexual relations (marital or extramarital) or a change in the pattern of sexual relations (such as when the couple begins or stops using contraception). 2. The psychological background consists, in most cases, of a desire for or fear of pregnancy. In the minority of patients mixed feelings toward pregnancy, desire and fear, are present simultaneously. 3. The anatomic and functional status is generally normal. 4. A benign course is the rule and, with the diagnosis once established, frank explanation and reassurance are sufficient to restore the normal cycle. The differential diagnosis between normal pregnancy, incipient abortion or incomplete abortion, and, in few patients, an ectopic pregnancy, may be rather difficult. A pregnancy test, diagnostic curettage, and puncture of the pouch of Douglas may be re-
features
The presenting symptom is usually a delay of 10 to 60 days in the appearance of menstruation, followed by an abnormal type of bleeding (it may be prolonged and profuse or may consist of a few days of spotting). Few patients present themselves with an abnormal type of bleeding without an associated delay in the appearance of menstrua-
From Obstetrical Departments “B,” Hospitals.
and Gynecological Hadassa Municipal
137
lirml
20
5
2
Patients with fear of pregnancy (8)
Patients with mixed ferlings (3)
~ Regular
~
Patients with desire for pregnancy or fear of sterility
Psychological background
17 -~ ..-.-._
___-2
-
-
~-4 ^_--.
1
I
2
cycle
-
3
4
i Irregular
1
1
8
-~Menstrual~ I delay only
I
I
/
1
6
14
b abnormal” I bleeding
/
-.
1
‘)
ma1* I 1 bleeding / Od}’
1 Abner-
/
fo?fizid
~
)yrnptom
’ Menstrual
Present
/
Diagnostic
6
1
3
1
Pregnanq test negative
--.
appeared
Diagnostic
1
‘)
8
j IPreguanc) / test 1 aegatirje
I
-
1
4
Diagnostir, curettage
j
tests .-------r
5
1
1
3
testr ~~___-.
following
symptoms appeared age 26.3 years i
3
1
1
1
Abnornal” bleeding 01113
in whom (average
12 -
?
4
6
br abnormal* bleeding
followed
Menstrual delay
symptoms
symptom ..___
in whom
Presenting
Menstrual delay only
--
of 19 patients
of clinical features of 3-k patients in the pattrrn of se>tual relations
or spotting.
Table II. Summary following a change
bleeding
4
Patients with mixed feelings (4) --___~Total
‘Profuse
6
Patients with fear of pregnancy (6)
2
Irregular
cycle
features
Usual
I Regular
of clinical
7
Psychological background
I. Summary
Patients with desire for pregnancy or fear of sterility (9)
Table
4
1
3
3
Douglni puncture 1 or culdoscopy
j
I
inrlolzred
itrr~olr~ed
-___ -
beginning ~~
and
8
1
6
10
8
1
9
2
0
13
Cycle, preguanc)‘.! and 1 deliuery
I j
F0110w-up -..~~~ ._ ~_.__ ~
10
2
2
deliuery
4
T i ) / Habitual 1 cycle i renewed
Cyde,
pregnancy,
2
Habitual cycle renewed
FogmLp
.-.
1
6
/ ! Recession
I I I
4
1
1
2
Recession
-1
age 23.2 years)
6
1
life (average
3
4
Patients without any interuention
/ Patient i without an)’ i iaterr,en1 tion
: I
I ’
I
of sexual
.~~.
Volume Number
91 1
quired in order to exclude some of these possibilities. In a number of patients definite diagnosis would be possible only retrospectively. The disorder, if not treated, may repeat itself in a number of successive periods. In some patients it recurs with every change in the pattern of sexual relations. The microscopic appearance of the endometrium, when a diagnostic curettage is performed, is not characteristic. In our patients it showed late proliferative or early secretory phase, not concomitant with the date of the last period. Puncture of the pouch of Douglas yields serous or serosanguinous fluids in amounts of 5 to 20 c.c. Clinical features of our cases. The clinical features as seen in our 53 patients are summarized in Tables I and II. We distinguished clinically between two groups of patients: (1) those in whom symptoms appeared after beginning sexual life, and (2) those in whom they occurred in changing the pattern of sexual life. In the vast majority (44 patients) the cycle was usually regular. The chief presenting symptom was menstrual delay or one followed by an abnormal kind of bleeding. Desire for pregnancy was the psychological background in 75 per cent of the patients in Group B and 50 per cent in Group A. In nearly half of the patients of both groups diagnosis was made clinically. The other half required one or several interventions. The follow-up showed the benign course of the disorder, regular menstrual cycle being achieved in most patients; in nearly half of the patients in both groups pregnancies and deliveries were subsequently seen. A considerable number (12 patients) in both groups showed “recession” under similar conditions. Comment
The classification of this disorder as a separate entity in the large group of menstrual disorders of psychogenic origin could be met by a number of oppositions: 1. A menstrual disorder is described
Unexplained
delayed
menstrual
period
139
which follows beginning of sexual relations or a change in their pattern. A desire or fear of pregnancy is present. But the simple chronological sequence of the two events does not as yet prove that a causal relationship exists between them, even when seen in a large number of cases. This is the usual problem with which one is always confronted in psychosomatic medicine. It seems that this relationship could be proved reasonably enough by the follow-up in these patients. It shows clearly that the disorder is functional and lacks any anatomopathological substrate: it is temporary and benign and the reproductive capacities of these patients proves to be normal. No other logical etiology seems common to all of them except the one that has been proposed. 2. The sexual act is such a highly complicated psychological event that some would oppose speaking of it as a unit. But for the clinical definition of the syndrome: it does not seem necessary to look, in every case, for the specific component involved, which surely will not be common to all the patients. 3. The third and, probably most important, opposition is that the psychological problem proposed is one confronted by every woman, so the disorder should, naturally, be very common. The answer is (1) that it is fairly common and every gynecologist surely has noticed it in his daily practice; (2) one must remember that in such a temporary and mild disorder the physician is not always consulted; (3) that this condition may sometimes be discovered in the past history of patients coming for other disorders, if they are especially asked about it; and (4) that the most important reason is that to resolve “stress problems” in such a way is not the normal reaction pattern expected. Normally the “intellectual center” should be able to deal with them successfully. Using “body language” (menstrual delay and bleeding) is a psychological failure of the higher centers and this represents some form of regression.’
140
Soferman
and
Haimov
4. A fourth possible opposition that may held by some is that part of the cases presented are really early complete or incomplete abortions. In 17 patients a “pregnancy test” was found negative. In 10 other patients a diagnostic curettage did not show changes consistent with pregnancy. So in nearly half of our patients pregnancy had been excluded objectively. In the remaining half pelvic examination and follow-up were sufficient to exclude it. This kind of opposition really does not change the problem materially. It does not deny the csistence of the syndrome. but only postulates a possible anatomopathological explanation for a disorder which already exists. We have already stressed before that in establishing the diagnosis a normal or pathological pregnancy should be excluded. In this very resemblance lies the clinical significance of the syndrome seen in this group of cases. Psychological factors, as a cause of various kinds of menstrual and hormonal disorders, have been shown clinically and experimentally. Novak and Harnik” have been able to achieve menstrual delay using hypnosis. Loeser’ has described typical cases of “gonadal arrest” caused by sudden stress. Klinefelter, Albright, and Griswold’ have proved the ability of stress to inhibit LH secretion and to prevent production of estrogen. The mechanism generally imsolved in psychosomatic gynecologic disorders has been presented schematically by Mandy and Mandy.” No special stress has been laid in this study to clarify the exact mechanism OI mechanisms involved, our principa1 aim bein~q for the present time to clarify the clinical picture. It is important to note that to carry out hormonal or other studies in these patients is an extremely difficult task because generally duration of symptoms is brief, and the patient is seen late, when hormonal changes are difficult to trace. There are several reasons justifying a separate clinical definition of the disorder encountered in these patients: 1. It closely simulates incipient or incombe
plete abortion, and in a considerable numpregnancy. Its ber of cases, extrauterine recognition would enable one to hold a conservative attitude, sparing surgical intervention. 2. Explaining it to married couples seeking advice concerning sexual life and contraception, some cases can be prevented and unnecessary concern dispensed with. 3. A clearly defined syndrome in medicine always makes diagnosis easier and attracts more attention than a vaguely described phenomenon. The syndrome should be diagnosed by its characteristic clinical features and not “per exclusion.” As in every psychosomatic disorder, meticulous care should be exercisrd not to overlook an underlying organic pathology, and in a number of patients only a retrograde diagnosis would be possible. As far as therapy is concerned, frank discussion and sympathetic reassurance would be able to remove much of the apprehension involved in most cases, with re-establishment of a normal cycle. This type of minor psychotherapy obtains good therapeutic results also as far as the prevention is concerned. Summary
A functional menstrual disorder consisting of a separate nosologic entity in the group of menstrual disorders of psychogenic origin, as seen in 53 patients, was described. The principal clinical features of this disorder arc: (1) a menstrual delay followed by an abnormal kind of bleeding; (2) normal anatomical and functional capacities; (3) a clearly recognized association between thr appearance of symptoms and beginning of sexual life or change in its patterns (as stopping use of contraceptives) ; (4) a psychological background consisting of fear of or desire for pregnancy; and (5) a generail) benign clinical course. The disorder described above bears cleat clinicai significance due to its resemblance to some pathological varieties of early pregnancy, I.e., incipient or incomplete abortions and ectopic pregnancy.
Volutnc Number
91 1
Unexplained
delayed
menstrual
period
141
REFERENCES
1. 2. 3.
M.: Harefuah Soferman, N., and Haimov, 64: 54, 1963. MacLean, P. D.: Psychozom. Med. 11: 338, 1919. Novak, J., and Harnik, M.: Zentralbl. f. Gynlk. 53: 2976, 1929.
4. 5.
6.
Locser, A. A.: Lancet 1: 518, 1943. Klinefelter, H. F., Jr., Albright, F., and 3: 529, Griswold, G. C.: J. Clin. Endocrinol. 1939. Mandy, A. D., and Mandy, T. E.: AM. J. OBST. & GYNEC. 60: 605, 1950.
OPINION
Pertinent comments
The syndrome of the unexplained delayed menstrual N.
SOFERMAN,
M.
HAIMOV,
Tel-Aviv,
period M.D. M.D.
Israel
F u N c T I o N A L menstrual disorders of psychogenic etiology are well known. The purpose of this paper is to present a group of cases in which a specific type of menstrual disorder is seen, closely associated with the very beginning of sexual life, or a sudden change in its pattern. The clinical picture which is well defined, bears great resemblance to some pathological varieties of early pregnancy, so its classification as a separate nosologic entity seems desirable. We have already presented some of these cases in a preliminary report.’ Clinical
tion. Part of these patients also have some of the subjective symptoms of pregnancy such as nausea, vertigo, breast engorgement, etc. In others an unusual pain may be present, concentrated principally in the lower abdomen. They all have some of the following additional characteristic features in common : 1. The disorder follows beginning of sexual relations (marital or extramarital) or a change in the pattern of sexual relations (such as when the couple begins or stops using contraception). 2. The psychological background consists, in most cases, of a desire for or fear of pregnancy. In the minority of patients mixed feelings toward pregnancy, desire and fear, are present simultaneously. 3. The anatomic and functional status is generally normal. 4. A benign course is the rule and, with the diagnosis once established, frank explanation and reassurance are sufficient to restore the normal cycle. The differential diagnosis between normal pregnancy, incipient abortion or incomplete abortion, and, in few patients, an ectopic pregnancy, may be rather difficult. A pregnancy test, diagnostic curettage, and puncture of the pouch of Douglas may be re-
features
The presenting symptom is usually a delay of 10 to 60 days in the appearance of menstruation, followed by an abnormal type of bleeding (it may be prolonged and profuse or may consist of a few days of spotting). Few patients present themselves with an abnormal type of bleeding without an associated delay in the appearance of menstrua-
From Obstetrical Departments “B,” Hospitals.
and Gynecological Hadassa Municipal
137
lirml
20
5
2
Patients with fear of pregnancy (8)
Patients with mixed ferlings (3)
~ Regular
~
Patients with desire for pregnancy or fear of sterility
Psychological background
17 -~ ..-.-._
___-2
-
-
~-4 ^_--.
1
I
2
cycle
-
3
4
i Irregular
1
1
8
-~Menstrual~ I delay only
I
I
/
1
6
14
b abnormal” I bleeding
/
-.
1
‘)
ma1* I 1 bleeding / Od}’
1 Abner-
/
fo?fizid
~
)yrnptom
’ Menstrual
Present
/
Diagnostic
6
1
3
1
Pregnanq test negative
--.
appeared
Diagnostic
1
‘)
8
j IPreguanc) / test 1 aegatirje
I
-
1
4
Diagnostir, curettage
j
tests .-------r
5
1
1
3
testr ~~___-.
following
symptoms appeared age 26.3 years i
3
1
1
1
Abnornal” bleeding 01113
in whom (average
12 -
?
4
6
br abnormal* bleeding
followed
Menstrual delay
symptoms
symptom ..___
in whom
Presenting
Menstrual delay only
--
of 19 patients
of clinical features of 3-k patients in the pattrrn of se>tual relations
or spotting.
Table II. Summary following a change
bleeding
4
Patients with mixed feelings (4) --___~Total
‘Profuse
6
Patients with fear of pregnancy (6)
2
Irregular
cycle
features
Usual
I Regular
of clinical
7
Psychological background
I. Summary
Patients with desire for pregnancy or fear of sterility (9)
Table
4
1
3
3
Douglni puncture 1 or culdoscopy
j
I
inrlolzred
itrr~olr~ed
-___ -
beginning ~~
and
8
1
6
10
8
1
9
2
0
13
Cycle, preguanc)‘.! and 1 deliuery
I j
F0110w-up -..~~~ ._ ~_.__ ~
10
2
2
deliuery
4
T i ) / Habitual 1 cycle i renewed
Cyde,
pregnancy,
2
Habitual cycle renewed
FogmLp
.-.
1
6
/ ! Recession
I I I
4
1
1
2
Recession
-1
age 23.2 years)
6
1
life (average
3
4
Patients without any interuention
/ Patient i without an)’ i iaterr,en1 tion
: I
I ’
I
of sexual
.~~.
Volume Number
91 1
quired in order to exclude some of these possibilities. In a number of patients definite diagnosis would be possible only retrospectively. The disorder, if not treated, may repeat itself in a number of successive periods. In some patients it recurs with every change in the pattern of sexual relations. The microscopic appearance of the endometrium, when a diagnostic curettage is performed, is not characteristic. In our patients it showed late proliferative or early secretory phase, not concomitant with the date of the last period. Puncture of the pouch of Douglas yields serous or serosanguinous fluids in amounts of 5 to 20 c.c. Clinical features of our cases. The clinical features as seen in our 53 patients are summarized in Tables I and II. We distinguished clinically between two groups of patients: (1) those in whom symptoms appeared after beginning sexual life, and (2) those in whom they occurred in changing the pattern of sexual life. In the vast majority (44 patients) the cycle was usually regular. The chief presenting symptom was menstrual delay or one followed by an abnormal kind of bleeding. Desire for pregnancy was the psychological background in 75 per cent of the patients in Group B and 50 per cent in Group A. In nearly half of the patients of both groups diagnosis was made clinically. The other half required one or several interventions. The follow-up showed the benign course of the disorder, regular menstrual cycle being achieved in most patients; in nearly half of the patients in both groups pregnancies and deliveries were subsequently seen. A considerable number (12 patients) in both groups showed “recession” under similar conditions. Comment
The classification of this disorder as a separate entity in the large group of menstrual disorders of psychogenic origin could be met by a number of oppositions: 1. A menstrual disorder is described
Unexplained
delayed
menstrual
period
139
which follows beginning of sexual relations or a change in their pattern. A desire or fear of pregnancy is present. But the simple chronological sequence of the two events does not as yet prove that a causal relationship exists between them, even when seen in a large number of cases. This is the usual problem with which one is always confronted in psychosomatic medicine. It seems that this relationship could be proved reasonably enough by the follow-up in these patients. It shows clearly that the disorder is functional and lacks any anatomopathological substrate: it is temporary and benign and the reproductive capacities of these patients proves to be normal. No other logical etiology seems common to all of them except the one that has been proposed. 2. The sexual act is such a highly complicated psychological event that some would oppose speaking of it as a unit. But for the clinical definition of the syndrome: it does not seem necessary to look, in every case, for the specific component involved, which surely will not be common to all the patients. 3. The third and, probably most important, opposition is that the psychological problem proposed is one confronted by every woman, so the disorder should, naturally, be very common. The answer is (1) that it is fairly common and every gynecologist surely has noticed it in his daily practice; (2) one must remember that in such a temporary and mild disorder the physician is not always consulted; (3) that this condition may sometimes be discovered in the past history of patients coming for other disorders, if they are especially asked about it; and (4) that the most important reason is that to resolve “stress problems” in such a way is not the normal reaction pattern expected. Normally the “intellectual center” should be able to deal with them successfully. Using “body language” (menstrual delay and bleeding) is a psychological failure of the higher centers and this represents some form of regression.’
140
Soferman
and
Haimov
4. A fourth possible opposition that may held by some is that part of the cases presented are really early complete or incomplete abortions. In 17 patients a “pregnancy test” was found negative. In 10 other patients a diagnostic curettage did not show changes consistent with pregnancy. So in nearly half of our patients pregnancy had been excluded objectively. In the remaining half pelvic examination and follow-up were sufficient to exclude it. This kind of opposition really does not change the problem materially. It does not deny the csistence of the syndrome. but only postulates a possible anatomopathological explanation for a disorder which already exists. We have already stressed before that in establishing the diagnosis a normal or pathological pregnancy should be excluded. In this very resemblance lies the clinical significance of the syndrome seen in this group of cases. Psychological factors, as a cause of various kinds of menstrual and hormonal disorders, have been shown clinically and experimentally. Novak and Harnik” have been able to achieve menstrual delay using hypnosis. Loeser’ has described typical cases of “gonadal arrest” caused by sudden stress. Klinefelter, Albright, and Griswold’ have proved the ability of stress to inhibit LH secretion and to prevent production of estrogen. The mechanism generally imsolved in psychosomatic gynecologic disorders has been presented schematically by Mandy and Mandy.” No special stress has been laid in this study to clarify the exact mechanism OI mechanisms involved, our principa1 aim bein~q for the present time to clarify the clinical picture. It is important to note that to carry out hormonal or other studies in these patients is an extremely difficult task because generally duration of symptoms is brief, and the patient is seen late, when hormonal changes are difficult to trace. There are several reasons justifying a separate clinical definition of the disorder encountered in these patients: 1. It closely simulates incipient or incombe
plete abortion, and in a considerable numpregnancy. Its ber of cases, extrauterine recognition would enable one to hold a conservative attitude, sparing surgical intervention. 2. Explaining it to married couples seeking advice concerning sexual life and contraception, some cases can be prevented and unnecessary concern dispensed with. 3. A clearly defined syndrome in medicine always makes diagnosis easier and attracts more attention than a vaguely described phenomenon. The syndrome should be diagnosed by its characteristic clinical features and not “per exclusion.” As in every psychosomatic disorder, meticulous care should be exercisrd not to overlook an underlying organic pathology, and in a number of patients only a retrograde diagnosis would be possible. As far as therapy is concerned, frank discussion and sympathetic reassurance would be able to remove much of the apprehension involved in most cases, with re-establishment of a normal cycle. This type of minor psychotherapy obtains good therapeutic results also as far as the prevention is concerned. Summary
A functional menstrual disorder consisting of a separate nosologic entity in the group of menstrual disorders of psychogenic origin, as seen in 53 patients, was described. The principal clinical features of this disorder arc: (1) a menstrual delay followed by an abnormal kind of bleeding; (2) normal anatomical and functional capacities; (3) a clearly recognized association between thr appearance of symptoms and beginning of sexual life or change in its patterns (as stopping use of contraceptives) ; (4) a psychological background consisting of fear of or desire for pregnancy; and (5) a generail) benign clinical course. The disorder described above bears cleat clinicai significance due to its resemblance to some pathological varieties of early pregnancy, I.e., incipient or incomplete abortions and ectopic pregnancy.
Volutnc Number
91 1
Unexplained
delayed
menstrual
period
141
REFERENCES
1. 2. 3.
M.: Harefuah Soferman, N., and Haimov, 64: 54, 1963. MacLean, P. D.: Psychozom. Med. 11: 338, 1919. Novak, J., and Harnik, M.: Zentralbl. f. Gynlk. 53: 2976, 1929.
4. 5.
6.
Locser, A. A.: Lancet 1: 518, 1943. Klinefelter, H. F., Jr., Albright, F., and 3: 529, Griswold, G. C.: J. Clin. Endocrinol. 1939. Mandy, A. D., and Mandy, T. E.: AM. J. OBST. & GYNEC. 60: 605, 1950.