Menstrual Disorders

Oguchi A. Nwosu M.D. Assistant Profressor Emory Family Medicine Dept. 6/28/07

Menstrual Cycle

Definitions
Menorrhagia Excessive (>80ml) uterine bleeding
Prolonged (>7days) regular

DUB Abnormal Bleeding, no obvious organic cause

usually anovulatory

Oligomenorrhea Uterine bleeding occurring at

intervals between 35 days and 6 months

Amenorrhea No menses x at least 6 months Metrorragia, Menometrorrhagia, Polymenorrhea

Ovulatory vs Anovulatory cycles

Anovulatory
Oligo or Amenorrhea +/- Menorrhagia

Ovulatory
Regular menstrual cycles (plus premenstrual symptoms such as dysmenorrhea and mastalgia

DUB
-Defn: Excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease -Diagnosis of exclusion - Anovulatory -Usually extremes of reproductive life and in pts with PCOS

DUB pathophysiology
Disturbance in the HPO axis thus changes in length of menstrual cycle No progesterone withdrawal from an estrogen-primed endometrium Endometrium builds up with erratic bleeding as it breaks down.

16year old with daily heavy vaginal bleeding with clots, no cramps
5ft 7in, 105ibs, normal sec. sex xristics, pelvic normal Menarche 14, 2 periods last year, heavy lasts 2 weeks, virginal. I month hx of daily heavy vag bleeding with clots, 8 to 10 pads x day No associated symptoms

Picture of teenager

DUB management
HCG, CBC, TSH ? Coagulation workup Ensure pap smear UTD if appropriate >35 or Ca risk factors, tamoxifen use sample endometrium

DUB management
I/V or I/M conjugated estrogen therapy acute DUB--How ?!!!. Usually followed by OCP or progestin Cyclic progestins for 10 to 12 days each cycle, consider mirena IUD OCP D and C old school, no longer recommended.

Menorrhagia
-Heavy vaginal bleeding that is not DUB -Usually secondary to distortion of uterine cavity- heavy with or without prolongation (anatomic). Uterus unable to contract down on open venous sinuses in the zona basalis -Other causes organic, endocrinologic, hemostatic and iatrogenic -Usually ovulatory

40 year old with menorrhagia x 12 months

5ft5, 155Ibs, husband castrated Had normal 28 day cycles lasting 5 days Last 1 year or so very heavy periods with clots and occ. flooding in the first 3 days with need to use >8pads/day fully soaked, spots for up to 1 week after this. Dysmenorrhea, severe, aching pain lower legs Normal recent pap

Picture of middle aged woman

Menorrhagia, Management
History Physical exam-anemia, obesity, androgen excess
e.g. hirsuitism, acne, ecchymosis/purpura, thyroid, galactorrhea, liver/spleen, Pelvic- Uterine, cervical and adnexal

Menorrhagia, management
HCG, CBC, TSH ? Coagulation workup Ensure pap smear UTD if appropriate >35 or Ca risk factors, tamoxifen use sample endometrium Other tests as INDICATED by HX and PE

Endometrial evaluation of menorrhagia

Endometrial Biopsy Transvaginal Ultrasound (TVS) Saline Infusion SonohysteroscOpy (SIS) Hysteroscopy
Sensitivity -91% Office procedure, well tolerated, anesthesia False positive rate -2% and cervical dilation usually not required

Sensitivity -88%

Good visualization of fibroids; may fail to identify other intracavitary abnormalities like polyps Procedure of choice (detection and cost). Sterile isotonic fluid is instilled into the uterus under continuous visualization of endometrium with TVS Highest cost. Better in pre-menopausal women. Does not reduce hysterectomy rate even without intracavitary path. Used as gold standard for other procedures

Sensitvity -97% NPV -94%

Sensitivity -100%

Menorrhagia, medical management

NSAIDs, 1 line, 5 days, decrease prostaglandins Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks,
st

androgenic side effects

OCPs, esp. if contraception desired, up to 60% dec. supp. HP axis Continous OCPs Oral continous progestins (day 5 to 26), most
prescribed, antiestrogen, downregulates endormetrium approaches surgical techniques

Levonorgestrel IUD (Mirena), High satisfaction rate that GnRH agonists, Inhibit FSH and LH release hypogonadism, bone Conjugated estrogens for acute bleeding
Other treatments as indicated e.g. DDAVP for coagulation defects

Menorrhagia, surgical management

Ablation

UAE Surgical

Myomectomy

?D&C

Hysterectomy

Menorrhagia, Surgical Management

Ablation

2nd Generation

1st Generation Resection (TCRE)

Cryoablation

Rollerball

Radiofrequency

Thermal Baloon

Microwave

Menorrhagia, management summary

Tailor treatment to individual patient. Consider patients age, coexisting medical diseases, FH, desire for fertility, cost of rx and adverse effects Surgical management reserved for organic causes (e.g fibroids) or when medical management fails to alleviate symptoms

Amenorrhea, physiologic causes

Male gender Prepubertal female Pregnant female Postmenopausal female

Primary Amenorrhea
Absence of menses by age 14 with absence of SSC (e.g. breast development) or absence by age 16 with normal SSC Only 3 conditions unique to primary, other causes of amenorrhea can cause either -Vaginal agenesis -Androgen insensitivity syndrome -Turners syndrome (45, X0)

Amenorrhea, causes
Generalized pubertal delay e.g. Turner syndrome Normal puberty e.g. PCOS Abnormalities of the genital tract e.g. Ashermans syndrome

Amenorrhea, management
Hx. PE- These are probably the most important aspects in diagnosis Remember to always rule out pregnancy H & P suggests Ovarian-axis problem- TSH, prolactin, FSH, LH Hirsuitism-Testosterone, DHEAS, androstenedione and 17-OH progesterone Chronic ds.- ESR, LFTs, BUN, cr and UA CNS- MRI

Amenorrhea, management
If H and P gives no clues to diagnosisexciting Use step wise approach to diagnosis

Evaluation of Secondary Amenorrhea

TABLE 4 Causes of Amenorrhea Hyperprolactinemia Prolactin 100 ng per mL (100 mcg per L) Altered metabolism Liver failure Renal failure Ectopic production Bronchogenic (e.g., carcinoma) Gonadoblastoma Hypopharynx Ovarian dermoid cyst Renal cell carcinoma Teratoma Breastfeeding Breast stimulation Hypothyroidism Medications Oral contraceptive pills Antipsychotics Antidepressants Antihypertensives Histamine H2 receptor blockers Opiates, cocaine Prolactin > 100 ng per mL Empty sella syndrome Pituitary adenoma Hypergonadotropic Hypogonadotropic hypogonadism hypogonadism (continued) Gonadal dysgenesis Excessive exercise Turner's syndrome* Excessive weight loss or malnutrition Other* Hypothalamic or pituitary destruction Postmenopausal ovarian failure Kallmann syndrome* Premature ovarian failure Sheehan's syndrome Autoimmune Normogonadotropic Chemotherapy Congenital Galactosemia Androgen insensitivity Genetic syndrome* 17-hydroxylase Mllerian agenesis* deficiency syndrome Hyperandrogenic anovulation Idiopathic Acromegaly Mumps Androgen-secreting tumor Pelvic radiation (ovarian or adrenal) Hypogonadotropic Cushing's disease hypogonadism Exogenous androgens Anorexia or bulimia nervosa Nonclassic congenital adrenal Central nervous system tumor hyperplasia Constitutional delay of growth Polycystic ovary syndrome and puberty* Thyroid disease Chronic illness Outflow tract obstruction Chronic liver disease Asherman's syndrome Chronic renal Cervical stenosis insufficiency Imperforate hymen* Diabetes Transverse vaginal septum* Immunodeficiency Other Inflammatory bowel Pregnancy disease Thyroid disease Thyroid disease Severe depression or psychosocial stressors Cranial radiation

*-Causes of primary amenorrhea only. Information from references 3, 6, and 15.

Abnormal Menstruation
Heres what you need to remember!!
Always R/O pregnancy, check pap Try to differentiate anovulatory from ovulatory bleeding Good history and physical is key( this applies to amenorrhea as well) Do a focused work up based on your H & P rather than a random set of studies In amenorrhea, where no indication of cause based on H & P, follow the stepwise algorithm for diagnosis Know the INDICATIONS for endometrial sampling

References
Slides 25 and 26 courtesy of: Master-Hunter T, Heiman D, Amenorrhea: Evaluation and Treatment. AFP April 15th 2006.