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Menstrual disorders

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o&g update course 2012 hospital segamat

o&g update course 2012 hospital segamat

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  • 1. Menstrual DisordersMenstrual Disorders DR:HUSSEIN H AKLDR:HUSSEIN H AKL O&G SPECIALISTO&G SPECIALIST MOH MALAYSIAMOH MALAYSIA 18 nov.201218 nov.2012
  • 2. Menstrual CycleMenstrual Cycle
  • 3. DefinitionsDefinitions MenorrhagiaMenorrhagia Excessive (>80ml) uterine bleedingExcessive (>80ml) uterine bleeding Prolonged (>7days) regularProlonged (>7days) regular DUBDUB Abnormal Bleeding, no obvious organic causeAbnormal Bleeding, no obvious organic cause usually anovulatoryusually anovulatory OligomenorrheaOligomenorrhea Uterine bleeding occurring atUterine bleeding occurring at intervals between 35 days and 6 monthsintervals between 35 days and 6 months AmenorrheaAmenorrhea No menses x at least 6 monthsNo menses x at least 6 months Metrorragia, Menometrorrhagia,Metrorragia, Menometrorrhagia, PolymenorrheaPolymenorrhea
  • 4. Ovulatory vs Anovulatory cyclesOvulatory vs Anovulatory cycles AnovulatoryAnovulatory Oligo or Amenorrhea +/- MenorrhagiaOligo or Amenorrhea +/- Menorrhagia OvulatoryOvulatory Regular menstrual cycles (plus premenstrual symptoms such asRegular menstrual cycles (plus premenstrual symptoms such as dysmenorrhea and mastalgiadysmenorrhea and mastalgia
  • 5. DUBDUB -Defn: Excessively heavy, prolonged or-Defn: Excessively heavy, prolonged or frequent bleeding of uterine origin that isfrequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemicnot due to pregnancy, pelvic or systemic diseasedisease -Diagnosis of exclusion-Diagnosis of exclusion - Anovulatory- Anovulatory -Usually extremes of reproductive life and in-Usually extremes of reproductive life and in pts with PCOSpts with PCOS
  • 6. DUB pathophysiologyDUB pathophysiology Disturbance in the HPO axis thus changesDisturbance in the HPO axis thus changes in length of menstrual cyclein length of menstrual cycle No progesterone withdrawal from anNo progesterone withdrawal from an estrogen-primed endometriumestrogen-primed endometrium Endometrium builds up with erraticEndometrium builds up with erratic bleeding as it breaks down.bleeding as it breaks down.
  • 7. 16year old with daily heavy vaginal16year old with daily heavy vaginal bleeding with clots, no crampsbleeding with clots, no cramps 5ft 7in, 105ibs, normal5ft 7in, 105ibs, normal sec. sex xristics, pelvicsec. sex xristics, pelvic normalnormal Menarche 14, 2 periodsMenarche 14, 2 periods last year, heavy lasts 2last year, heavy lasts 2 weeks, virginal.weeks, virginal. I month hx of daily heavyI month hx of daily heavy vag bleeding with clots, 8vag bleeding with clots, 8 to 10 pads x dayto 10 pads x day No associated symptomsNo associated symptoms Picture of teenagerPicture of teenager
  • 8. DUB managementDUB management HCG, CBC, TSHHCG, CBC, TSH ? Coagulation workup? Coagulation workup Ensure pap smear UTD if appropriateEnsure pap smear UTD if appropriate >35 or Ca risk factors, tamoxifen use>35 or Ca risk factors, tamoxifen use –– sample endometriumsample endometrium
  • 9. DUB managementDUB management I/V or I/M conjugated estrogen therapyI/V or I/M conjugated estrogen therapy acute DUB--How ?!!!.acute DUB--How ?!!!. Usually followed by OCP or progestinUsually followed by OCP or progestin Cyclic progestins for 10 to 12 days eachCyclic progestins for 10 to 12 days each cycle, consider mirena IUDcycle, consider mirena IUD OCPOCP D and C – old school, no longerD and C – old school, no longer recommended.recommended.
  • 10. MenorrhagiaMenorrhagia -Heavy vaginal bleeding that is not DUB-Heavy vaginal bleeding that is not DUB -Usually secondary to distortion of uterine-Usually secondary to distortion of uterine cavity- heavy with or without prolongationcavity- heavy with or without prolongation (anatomic).(anatomic). Uterus unable to contract down on openUterus unable to contract down on open venous sinuses in the zona basalisvenous sinuses in the zona basalis -Other causes organic, endocrinologic,-Other causes organic, endocrinologic, hemostatic and iatrogenichemostatic and iatrogenic -Usually ovulatory-Usually ovulatory
  • 11. 40 year old with menorrhagia x 1240 year old with menorrhagia x 12 monthsmonths 5ft’5”, 155Ibs, husband5ft’5”, 155Ibs, husband ‘castrated’‘castrated’ Had normal 28 day cyclesHad normal 28 day cycles lasting 5 dayslasting 5 days Last 1 year or so veryLast 1 year or so very heavy periods with clotsheavy periods with clots and occ. ‘flooding’ in theand occ. ‘flooding’ in the first 3 days with need tofirst 3 days with need to use >8pads/day fullyuse >8pads/day fully soaked, spots for up to 1soaked, spots for up to 1 week after this.week after this. Dysmenorrhea, severe,Dysmenorrhea, severe, aching pain lower legsaching pain lower legs Normal recent papNormal recent pap Picture of middlePicture of middle aged womanaged woman
  • 12. Menorrhagia,Menorrhagia, ManagementManagement HistoryHistory Physical exam-Physical exam-anemia, obesity, androgen excessanemia, obesity, androgen excess e.g. hirsuitism, acne, ecchymosis/purpura, thyroid,e.g. hirsuitism, acne, ecchymosis/purpura, thyroid, galactorrhea, liver/spleen, Pelvic- Uterine, cervical andgalactorrhea, liver/spleen, Pelvic- Uterine, cervical and adnexaladnexal
  • 13. Menorrhagia,Menorrhagia, managementmanagement HCG, CBC, TSHHCG, CBC, TSH ? Coagulation workup? Coagulation workup Ensure pap smear UTD if appropriateEnsure pap smear UTD if appropriate >35 or Ca risk factors, tamoxifen use>35 or Ca risk factors, tamoxifen use sample endometriumsample endometrium Other tests as INDICATED by HX and PEOther tests as INDICATED by HX and PE
  • 14. Endometrial evaluation ofEndometrial evaluation of menorrhagiamenorrhagia EndometrialEndometrial BiopsyBiopsy Sensitivity -91%Sensitivity -91% False positive rateFalse positive rate -2%-2% Office procedure, well tolerated,Office procedure, well tolerated, anesthesia and cervical dilation usually notanesthesia and cervical dilation usually not requiredrequired TransvaginalTransvaginal UltrasoundUltrasound (TVS)(TVS) Sensitivity -88%Sensitivity -88% Good visualization of fibroids; may fail toGood visualization of fibroids; may fail to identify other intracavitary abnormalitiesidentify other intracavitary abnormalities like polypslike polyps Saline InfusionSaline Infusion Sonohysterosc-Sonohysterosc- Opy (SIS)Opy (SIS) Sensitvity -97%Sensitvity -97% NPV -94%NPV -94% Procedure of choice (detection and cost).Procedure of choice (detection and cost). Sterile isotonic fluid is instilled into theSterile isotonic fluid is instilled into the uterus under continuous visualization ofuterus under continuous visualization of endometrium with TVSendometrium with TVS HysteroscopyHysteroscopy Sensitivity -100%Sensitivity -100% Highest cost. Better in pre-menopausalHighest cost. Better in pre-menopausal women. Does not reduce hysterectomywomen. Does not reduce hysterectomy rate even without intracavitary path. Usedrate even without intracavitary path. Used as gold standard for other proceduresas gold standard for other procedures
  • 15. Menorrhagia,Menorrhagia, medical managementmedical management NSAID’s,NSAID’s, 11stst line, 5 days, decrease prostaglandinsline, 5 days, decrease prostaglandins Danazol,Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks,Androgen and prog. competitor , amenorrhea in 4-6 weeks, androgenic side effectsandrogenic side effects OCP’s,OCP’s, esp. if contraception desired, up to 60% dec. supp. HP axisesp. if contraception desired, up to 60% dec. supp. HP axis Continous OCP’sContinous OCP’s Oral continous progestins (day 5 to 26),Oral continous progestins (day 5 to 26), mostmost prescribed, antiestrogen, downregulates endormetriumprescribed, antiestrogen, downregulates endormetrium Levonorgestrel IUD (Mirena),Levonorgestrel IUD (Mirena), High satisfaction rate thatHigh satisfaction rate that approaches surgical techniquesapproaches surgical techniques GnRH agonists,GnRH agonists, Inhibit FSH and LH release– hypogonadism, boneInhibit FSH and LH release– hypogonadism, bone Conjugated estrogens for acute bleedingConjugated estrogens for acute bleeding Other treatments as indicated e.g. DDAVP for coagulation defectsOther treatments as indicated e.g. DDAVP for coagulation defects
  • 16. Menorrhagia,Menorrhagia, surgical managementsurgical management UAE ? D & C Hysterect- omy Myomectomy Ablation Surgical
  • 17. Menorrhagia,Menorrhagia, Surgical ManagementSurgical Management Ablation 2nd Generation 1st Generation Resection (TCRE) Cryoablation Rollerball Radiofrequency Thermal Baloon Microwave
  • 18. Menorrhagia,Menorrhagia, management summarymanagement summary Tailor treatment to individual patient.Tailor treatment to individual patient. Consider patients age, coexisting medicalConsider patients age, coexisting medical diseases, FH, desire for fertility, cost of rxdiseases, FH, desire for fertility, cost of rx and adverse effectsand adverse effects Surgical management reserved forSurgical management reserved for organic causes (e.g fibroids) or whenorganic causes (e.g fibroids) or when medical management fails to alleviatemedical management fails to alleviate symptomssymptoms
  • 19. Amenorrhea,Amenorrhea, physiologic causesphysiologic causes LactationalLactational Prepubertal femalePrepubertal female Pregnant femalePregnant female Postmenopausal femalePostmenopausal female
  • 20. Primary AmenorrheaPrimary Amenorrhea Absence of menses by age 14 withAbsence of menses by age 14 with absence of SSC (e.g. breastabsence of SSC (e.g. breast development) or absence by age 16 withdevelopment) or absence by age 16 with normal SSCnormal SSC Only 3 conditions unique to primary, otherOnly 3 conditions unique to primary, other causes of amenorrhea can cause eithercauses of amenorrhea can cause either -Vaginal agenesis-Vaginal agenesis -Androgen insensitivity syndrome-Androgen insensitivity syndrome -Turners syndrome (45, X0)-Turners syndrome (45, X0)
  • 21. Amenorrhea,Amenorrhea, causescauses Generalized pubertal delay e.g. TurnerGeneralized pubertal delay e.g. Turner syndromesyndrome Normal puberty e.g. PCOSNormal puberty e.g. PCOS Abnormalities of the genital tract e.g.Abnormalities of the genital tract e.g. Ashermans syndromeAshermans syndrome
  • 22. Amenorrhea,Amenorrhea, managementmanagement Hx.Hx. PE- These are probably the most importantPE- These are probably the most important aspects in diagnosisaspects in diagnosis Remember to always rule out pregnancyRemember to always rule out pregnancy H & P suggestsH & P suggests - Ovarian-axis problem- TSH, prolactin, FSH, LHOvarian-axis problem- TSH, prolactin, FSH, LH - Hirsuitism-Testosterone, DHEAS,Hirsuitism-Testosterone, DHEAS, androstenedione and 17-OH progesteroneandrostenedione and 17-OH progesterone - Chronic ds.- ESR, LFT’s, BUN, cr and UAChronic ds.- ESR, LFT’s, BUN, cr and UA - CNS- MRICNS- MRI
  • 23. Amenorrhea,Amenorrhea, managementmanagement If H and P gives no clues to diagnosis-If H and P gives no clues to diagnosis- excitingexciting Use step wise approach to diagnosisUse step wise approach to diagnosis
  • 24. Evaluation of Secondary Amenorrhea
  • 25. 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 hypogonadism Gonadal dysgenesis Turner's syndrome* Other* Postmenopausal ovarian failure Premature ovarian failure Autoimmune Chemotherapy Galactosemia Genetic 17-hydroxylase deficiency syndrome Idiopathic Mumps Pelvic radiation Hypogonadotropic hypogonadism Anorexia or bulimia nervosa Central nervous system tumor Constitutional delay of growth and puberty* Chronic illness Chronic liver disease Chronic renal insufficiency Diabetes Immunodeficiency Inflammatory bowel disease Thyroid disease Severe depression or psychosocial stressors Cranial radiation Hypogonadotropic hypogonadism (continued) Excessive exercise Excessive weight loss or malnutrition Hypothalamic or pituitary destruction Kallmann syndrome* Sheehan's syndrome Normogonadotropic Congenital Androgen insensitivity syndrome* Müllerian agenesis* Hyperandrogenic anovulation Acromegaly Androgen-secreting tumor (ovarian or adrenal) Cushing's disease Exogenous androgens Nonclassic congenital adrenal hyperplasia Polycystic ovary syndrome Thyroid disease Outflow tract obstruction Asherman's syndrome Cervical stenosis Imperforate hymen* Transverse vaginal septum* Other Pregnancy Thyroid disease *-Causes of primary amenorrhea only. Information from references 3, 6, and 15.
  • 26. Abnormal MenstruationAbnormal Menstruation Here’s what you need to remember!!Here’s what you need to remember!! Always R/O pregnancy, check papAlways R/O pregnancy, check pap Try to differentiate anovulatory from ovulatory bleedingTry to differentiate anovulatory from ovulatory bleeding Good history and physical is key( this applies toGood history and physical is key( this applies to amenorrhea as well)amenorrhea as well) Do a focused work up based on your H & P rather than aDo a focused work up based on your H & P rather than a random set of studiesrandom set of studies In amenorrhea, where no indication of cause based onIn amenorrhea, where no indication of cause based on H & P, follow the stepwise algorithm for diagnosisH & P, follow the stepwise algorithm for diagnosis Know the INDICATIONS for endometrial samplingKnow the INDICATIONS for endometrial sampling
  • 27. Thank You Egypt
  • 28. ReferencesReferences Slides 25 and 26 courtesy of:Slides 25 and 26 courtesy of: Master-Hunter T, Heiman D, Amenorrhea:Master-Hunter T, Heiman D, Amenorrhea: Evaluation and Treatment. AFP April 15Evaluation and Treatment. AFP April 15thth 2006.2006.