OBSTETRICS & GYNECOLOGY

1. Menstrual Disorders
OBSTETRICS & GYNECOLOGY GROUP 3

2. MENSTRUAL DISORDERS
THE MENSTRUAL
CYCLE
HISTORY TAKING
&
INVESTIGATIONS
CASE
PRESENTATION
Explain the types of menstrual
disorders
&
Discuss its causes
Describe the normal
menstrual cycle
Discuss the required informations
during history taking
&
Explain the procedures performed
during investigations
Discuss about a particular
cases with relations to the
topic
LEARNING OUTCOMES

3. Menstruation (Days 1-4)
The endometrium sheds due to the hormonal support withdrawal, and
myometrial contractions occur which can be painful
( ↓ oestradiol/progesterone )
THE NORMAL MENSTRUAL CYCLE
Ovulation and changes in the endometrium that prepare it for
implantation if fertilization occur are all caused by hormonal changes of
the menstrual cycle
Proliferative phase (Days 5-13)
GnRH pulses from the hypothalamus stimulate LH and FSH release from
the anterior pituitary gland. This induces follicular growth.
The follicles produce oestradiol and inhibin which then suppresses FSH
secretion via negative feedback, causing only one follicle and oocyte
maturation.
Oestradiol levels continue to rise and reach their maximum, this causes a
positive feedback effect to the hypothalamus and pituitary gland causing
LH levels to rise sharply
Ovulation follows in the 36 hrs after the LH surge
Endometrium in this phase is re-formed and proliferative due to the
oestradiol. The stromal cells proliferate and glands elongate

4. Luteal/Secretory phase (Day 14-28)
Corpus luteum is formed from the follicle which the egg was released
from
Corpus luteum forms oestrogen and progesterone (more progesterone,
which levels peak at D21)
If no fertilization occurs, corpus luteum starts to fail causing the
progesterone and oestrogen levels to fall
Endometrium:
The progesterone induces secretory change in the endometrium; the
stromal cells enlarged, glands swell and blood supply increases.
But towards the end of this phase, once the corpus luteum starts to fail d/t
lack of fertilization → hormonal support is withdrawn → endometrium
breaks down → menstruation occurs and cycle restarts
THE NORMAL MENSTRUAL CYCLE
Ovulation and changes in the endometrium that prepare it for
implantation if fertilization occur are all caused by hormonal
changes of the menstrual cycle

5. ABNORMAL UTERINE BLEEDING
Prolonged (>7 days) and/or heavy (>80 mL) uterine bleeding occurring at regular intervals
Structural
● Polyp
● Adenomyosis
● Leiomyoma
● Malignancy
Non Structural
● Coagulopathy
● Ovulatory Dysfunction
● Endometrial Dysfunction
● Iatrogenic
● Not classified
Causes ●
- Age
- Blood Disorders
- Thyroid Disorders
- Endometriosis
- Ethnic or Culture Group
- Parity
- Lifestyle
- Genetics
Risk Factors

6. Focal endometrial outgrowths containing
a variable amount of glands, stroma &
blood vessels
Insensitive to cyclic hormonal changes
May be pedunculated or sessile, single or
multiple and vary in size (0.5 - 4 cm)
Risk Factors
- Obesity
- Late Menopause
- Use of tamoxifen (a partial oestrogen agonist)
- Possibly the use of Hormonal Replacement Therapy
Clinical Features
● Asymptomatic
● Abnormal Per Vaginal Bleed:
○ Heavy menstrual period
○ Post-menopausal bleed
○ Irregular bleeding (on HRT)
○ Intermenstrual bleeding
● Cramping pain (Uterus tries to expel polyp)
● Fertility issues
● Polyps may be visible in external os

7. - Transvaginal Ultrasound (Focal Thickening
of the endometrium)
- Office Hysteroscopy
- Saline infusion sonography (SIS)
Investigations
Transvaginal
Ultrasonography
Office Hysteroscopy
●
● Polypectomy using hysteroscopy
○ Under LA - Remove the polyp with scissors,
electrodes or morcellators
Management

8. Fibroids
Most Common Benign Tumour in
Female
Benign tumour of the uterine
smooth muscle “leiomyoma”
Oestrogen dependent, usually
multiple
PATHOPHYSIOLOGY
Fibroids have a high number of oestrogen & progesterone receptors compared
to the normal smooth muscle cells of the uterus, where oestrogen stimulates
the proliferation of the smooth muscle cells while progesterone increases the
production of cellular proteins that interfere with apoptosis.
Fibroids can undergo degeneration/secondary changes
Chronic
- Hyaline: Replacement of fibrous & smooth muscle tissues with hyaline
tissue (Fibroid outgrowth from blood supply - Asymptomatic)
- Cystic: Breakdown of hyaline substances with further reduction of blood
supply leading to central necrosis formation.
- Calcification: Final stage which particularly occurs after menopause
Acute
- Red Degeneration: Acute disruption of blood supply to the fibroid during
active growth classically during the mid 2nd trimester of pregnancy.
Present with the sudden onset of pain + localized tenderness + mild
pyrexia + leukocytosis

9. RISK FACTORS
1. Age group of 35 - 40
2. Hereditary (African Caribbean)
3. Race
4. High Oestrogen Level (Nulliparous,
HRT)
5. Obesity (Adipose Tissue →
Aromatization → High Oestrogen)
6. Nulliparous Women (Unopposed
Oestrogen)
CLINICAL FEATURES
MOSTLY ASYMPTOMATIC (Especially Intramural, pedunculated)
1. Mass Effect
● Bloating, early satiety
● Abdominal Distension
● Sense of heaviness in the lower abdomen
● Dull Back Ache/Pain
● Urinary Symptoms: Urinary Frequency, a large fibroid may cause urinary
retention or hydronephrosis
● Compression on colon → constipation/pain defecation
2. Abnormal Uterine Bleeding
● Heavy (Menorrhagia) or Intermenstrual Bleeding
● Usually Subserosal type
3. Dysmenorrhea
4. Acute Abdominal or Pelvic Pain
● Acute Pain arise due to red degeneration or torsion of pedunculated of
subserosal fibroids
5. Effects on fertility and pregnancy/Complication:
● Subfertility
● Early Pregnancy Loss
● Malpresentation
● Postpartum haemorrhage
● Preterm Labour

10. ENDOMETRIAL CARCINOMA & HYPERPLASIA
Risk Factors
- Early Menarche
- Late Menopause
- Tamoxifen users (Anti Oestrogenic in the breast BUT oestrogenic
in the endometrium)
- Obese
- HPT
Adenomyosis Endometrial Carcinoma Endometriosis
- DM
- Nulliparity
- PCOS
- Family history of Endometrial
Cancer
Most Common Malignancy Of The Female Genital Tract In The World

11. Clinical Features
Abnormal Per Vaginal Bleed
- Heavy menstrual bleeding with regular cycle, can be irregular bleeding
Advanced Stage
- Abdominal pain
- Urinary Dysfunction
- Bowel disturbances or respiratory symptoms
- Abdominal Distension (Ascites)
- Metastatic Symptoms
- Dyspnea
- Cough
- Hemoptysis
- LOW, LOA

14. AMENORRHOEA
Primary Amenorrhoea
Menstruation has not started by the
age of 16 with secondary sexual
characteristics
Menstruation has not started by the
age of 14 without secondary sexual
characteristics
Secondary Amenorrhoea
Previously normal menstruation ceases
for 6 consecutive months who
previously had regular menstruation
The absence of menstruation which may be temporary or permanent

15. RISK FACTORS OF AMENORRHOEA
● Family history of amenorrhoea
● Genetic or chromosomal condition that affects one’s menstrual
cycle
● Obese or underweight
● Over-exercising
● Stress
● Chronic illness

16. AETIOLOGY OF PRIMARY AMENORRHEA
Caused by external factors, low
weight/anorexia nervosa or excessive
exercise
Underactivity and overactivity of the
thyroid
Hypothyroidism and
Hyperthyroidism
Absence of the uterus,cervix and/or
vagina
MRKH Syndrome
Caused by pituitary hyperplasia or benign
adenomas
Hyperprolactinaemia
Hypothalamic Hypogonadism

17. ● Galactorrhea (Milky discharge from breast)
● Headache
● Weight loss
● Vision changes
● Hot flashes
● Vaginal dryness
● Acne
● Excessive hair growth on face and body
CLINICAL FEATURES OF
PRIMARY AMENORRHOEA
INVESTIGATIONS OF
PRIMARY AMENORRHOEA
● History taking
● Physical examination
● Pregnancy test
● Sexual Maturity Ratings(SMR)/ Tanner Stages
● Pelvic ultrasound
● Blood tests
● Karyotype

18. MANAGEMENT OF PRIMARY AMENORRHOEA
Hormone replacement
therapy
Cyclical progestogen
Contraceptive pill
Counselling

19. AETIOLOGY OF SECONDARY AMENORRHOEA
Hyperprolactinaemia
Most common cause. Serum
prolactin is elevated
Premature ovarian
insufficiency
Formerly known as
premature ovarian failure by
definition is the cessation of
periods accompanied by a
raised gonadotrophin level
prior to the age of 40
Early menopause
Polycystic ovary syndrome
(PCOS)
Hypersecretion of androgen
Hypersecretion of LH
Presence of two of the three
criterias:
1. Oligo-ovulation and/or
anovulation
2. Hyperandrogenism
3. Polycystic ovaries assessed
by ultrasound

20. CLINICAL FEATURES OF SECONDARY
AMENORRHOEA
● History taking
● Physical examination
● Pregnancy test
● Blood tests
● CT scan of pituitary
● Pelvic ultrasound
● Karyotype
● Galactorrhea (Milky discharge
from breast)
● Headache
● Weight loss
● Vision changes
● Hot flashes
● Vaginal dryness
● Acne
● Excessive hair growth on face
and body
INVESTIGATIONS OF
SECONDARY AMENORRHOEA

21. MANAGEMENT OF SECONDARY AMENORRHOEA
Hyperprolactinemia
Drug therapy
(Cabergoline)
POI
Estrogen
therapy+progestogen
(must be taken tgt to
prevent endometrial
thickening)
Surgery
PCOS
Focused on her
individual problems

22. Saturn is a gas giant and
has several rings. It's
composed of hydrogen
Tampon
Cup
DYSMENORRHEA
Abdominal pain that occurs during or is associated with
menstruation
Primary Secondary
● Menstrual pain without organic disease
● Onset between 6 to 12 months after
menarche, remains more or less constant
throughout
● Lower pelvic or abdominal pain, sharp &
intermittent, begins soon after onset of
menstruation, and usually associated
with onset of menstrual flow and lasts
8-72 hours.
● Menstrual pain associated with an
identifiable disease.
● Develops distant from the time of
menarche/primary dysmenorrhea
worsens as time goes by
● Pain - often begins mildly,
progressively increases in intensity
and duration, continuous, sharp,
located to one of the iliac regions or
both, tendency to radiate to the back
& thighs or legs, may also be mid
cycle or acyclic.

23. RISK FACTORS OF DYSMENORRHEA
Obesity
Duration of menstrual flow
Younger average of
menarche
Smoking, obesity, alcohol
consumption
Higher level of stress
Alcohol consumption

24. AETIOLOGY OF PRIMARY DYSMENORRHEA
Psychological
1
Elevated
vasopressin
2
Elevated
prostaglandin
3
Tension, anxiety, low pain threshold
Contraction of smooth muscle -> uterine hyperactivity -> dysrhythmics
contractions -> reduce uterine blood flow -> hypoxia -> ischemic pain.
Endometrial sloughing
- Endometrial cells release prostaglandins as
menstruation begins -> stimulate myometrial
contraction -> ischemia of myometrium

25. PRIMARY DYSMENORRHEA
● Cramping low abdominal
● Back and thigh pain
● Systemic symptoms : Headache,
diarrhea, nausea, vomiting, fever,
fatigue
● Relieved by NSAIDs & hormonal
meds, usually disappears after
term pregnancy
CLINICAL FEATURES INVESTIGATIONS
● History taking
- onset , location, duration,
characteristics of pain, and
aggravating or relieving factors
● Abdominal/pelvic examination -
unremarkable
● Ultrasound scanning does not reveal
any abnormality

26. PRIMARY DYSMENORRHEA
TREATMENT
● NSAIDS
- Inhibits COX-1 & COX-2
● Prostaglandins synthetase
inhibitor
- Inhibits COX enzyme -> inhibits
prostaglandin synthesis
● Combine OCP
- Inhibit ovulation -> reduce
menstrual prostaglandins levels->
reduce endometrium growth

27. AETIOLOGY
➔ Uterine fibroids
➔ Adenomyosis
➔ Endometriosis
➔ Pelvic inflammatory disease
INVESTIGATIONS
➔ Speculum examination - vaginal discharge or abnormal
bleeding
➔ Abdominal examination
- tenderness, mass arising from lower abdomen
➔ Imaging studies
- abdominal/transvaginal ultrasound
MANAGEMENT
● Manage the underlying pathology
○ Surgery
● Pain relief
CLINICAL FEATURES
➔ Dyspareunia
➔ Heavy and irregular bleeding
➔ Per vaginal discharge
➔ infertility
➔ Bowel & bladder symptoms
SECONDARY DYSMENORRHEA

28. CASE SUMMARY (AUB)
CHIEF COMPLAINT
Heavy Menstruation For 6 months
FULL HISTORY
42 year old G4P4 teacher went to KK Cheng for abnormal uterine bleeding for 6 months. She is apparently well and asymptomatic
until 6 months ago when there is an increase in flow and quantity of menstruation.
Before that, her flow was 4-5 days with 2 pads daily, but now it is 7-9 days with 3-4 pads daily. There is minimal blood clot. For her
current cycle, bleeding already stopped 2 days ago. She is also experiencing dysmenorrhea, but it started since menarche. Her cycle
is regular of 28 days. No inter-menstrual or post-coital bleed. She was also experiencing lethargy and palpitations. On examination,
she is pale, pulse is 108 bpm. Her blood group is A+.
All her children were born between 2000-2008 at term via spontaneous vaginal delivery. She was diagnosed with anaemia & GDM in
her last two pregnancies.
She had an appendectomy done in 1998 under GA and there were no complications. PAP smear was done twice back in 2001 & 2008
but there were no significant findings. OCP was used after each pregnancy and her last was in 2010. She is the first of 6 siblings with
a diabetic hypertensive father and a healthy mother. Her maternal aunt has GI carcinoma. She claims to not have any blood
disorders nor any gynecological problems in her family.
Patient lives with her husband and children at Malim about 15 minutes to MGH. She owns a car. Her husband is also a teacher. They
are financially and socially stable.
They are not smoking, does not alcohol and using recreational drug.

29. CASE SUMMARY (AUB)
General Physical Examination
Patient is alert, cooperative and lethargy. IV cannula inserted into her dorsum of left hand, connected to Normal Saline
Vitals:-
Pulse: 108 bpm, regular, low volume, no collapsing pulse, no thickening of vessel wall
Blood Pressure: 110/76 mmHg, right arm supine.
Respiratory Rate: 16 breaths per minute.
Temperature: Afebrile
Patient is pale. No koilonychia, platonychia.
No cyanosis, jaundice, ulcer. No swelling of the neck, no cervical and axillary lymphadenopathy.
No swelling of the breast. No pedal edema.
Local gynecological examination is unremarkable.
Investigation
FBC: Hb levels
8.1 g/dL (7/4/2014 9.00am)
7.9 g/dL (7/4/2014 4.00pm)
7.8 g/dL (8/4/2014)
Coagulation Profile: Normal
Ultrasound: No mass in vagina, uterus, ovary. Endometrial thickness: 6mm

30. References
https://www.slideshare.net/betheredz/abnormal-uterine-bleeding-ss
https://www.guidelines.co.uk/womens-health/nice-heavy-menstrual-bleeding-guideline/454104.article
Impey, L. & Child, Tim. Obstetrics & Gynaecology, 5th Edition, 2017, Chapter 2, The menstrual cycle and its disorders, Pp. 12-21.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459624/
Prof Hanif’s slides
JP8F.CO, Obstetrics & Gynaecology, 2nd Edition, 2016, Dysmenorrhea, Pp.83
Edmonds, D. K., Lees, C. & Bourne, Tom. Dewhurst’s Textbook of Obstetrics &
Gynaecology, 9th Edition, 2021, PCOS and Secondary Amenorrhea, Pp. 1264