Clinical manifestation of anovulation is oligomenorrhea or amenorrhea. Patients with hyperandrogenemia and polycystic ovaries (without ovulation disorders) and patients with polycystic ovaries and ovulation disorders (without hyperandrogenism) may now be included in polycystic ovary syndrome (PCOS) diagnosis. The majority of anovulatory patients (about 80%) will have normal serum concentrations of estradiol (E2) and follicle-stimulating hormone (FSH) and a small proportion (approximately 10%) decreased concentrations of both hormones. Traditionally, ovulation induction treatment in normogonadotropic anovulation is started with an antiestrogen (CC) and, in case of treatment failure or absence of conception, this is followed by exogenous FSH. The most serious complications resulting from ovulation induction are caused by the limited control of follicular development. Increased availability of genetic profiles will be helpful to accomplish a more patient-tailored approach by identification of beneficial subgroups for certain interventions.

Normal menstruation is the end product of a complex interplay of health and hormones. This chapter discusses the etiology, treatment and evaluation of amenorrhea, polycystic ovary disease and abnormal menstrual bleeding. Many of the causes of amenorrhea can also cause oligomenorrhea, metrorrhagia, menorrhagia, and other irregularities of menstruation. Primary amenorrhea occurs in adolescents who have never had a menstrual period. Women with amenorrhea can be placed on ovulation inducing drugs. An ovulation inducing agent, such as clomiphene is needed. Metformin may be used in those women with polycystic ovarian syndrome (PCOS). Metformin improves the endocrine symptoms of PCOS, even in women who are not diabetic. It treats insulin sensitivity, induces normal ovulatory cycles, and causes weight loss, although this is an off-label use. Heavy menstrual bleeding (HMB) is an important cause of ill health in women.

Perimenopause is the time in a woman's life when she begins to experience the changes that lead to menopause. Smoking and shorter menstrual cycles can cause earlier menopause, while multigravidity and use of oral contraceptive pills are associated with later menopause. There may be additional factors, including cultural differences that influence the age of menopause. The menstrual and urogenital changes associated with perimenopause can be very distressing. Menstrual patterns are altered in many ways, including menorrhagia, menometrorrhagia, oligomenorrhea, intermenstrual bleeding, polymenorrhea, postcoital bleeding, and postmenopausal bleeding. In one small survey, 93% of women reported one of these changes in the five years prior to menopause. The challenge for the provider is to distinguish between normal and abnormal bleeding. Ultrasonography has become the standard test in the evaluation of dysfunctional uterine and postmenopausal bleeding. Hysterectomy is the only way to stop menorrhagia completely.