Menstrual disorders


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Menstrual Disorders and their management

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Menstrual disorders

  1. 1. + Menstrual Disorders Dr.Ahmed Rashad PGY2 Family Medicine Under Supervision of Dr.Leena Kadhem
  2. 2. + Objectives  To understand the physiology of the normal menstrual cycle  To know definition and types of abnormal uterine bleeding  How to approach a case of abnormal uterine bleeding  Amenorrhea; types and causes  Dysmenorrhea; types and management  When to refer to secondary care
  3. 3. + Introduction  Menstrual disorders and abnormal uterine bleeding (AUB) are among the most frequent gynecologic complaints. [1]  Menstrual disorders frequently affect the quality of life of adolescents and young adult women and can be indicators of serious underlying problems.
  4. 4. + Normal Menstrual Cycle  The normal menstrual cycle is a tightly coordinated cycle of stimulatory and inhibitory effects that results in the release of a single mature oocyte from a pool of hundreds of thousands of primordial oocytes.
  5. 5. + H-P-O axis
  6. 6. +  The average adult menstrual cycle is 28 days, with a range of 24 to 35 days , and lasts four to six days.  The median blood loss during each menstrual period is 30 mL; the upper limit of normal is 80 mL.
  7. 7. + CASE 1 A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.
  8. 8. +  The patient’s bleeding pattern is best described as …?  The most likely diagnosis is …?  What is the most likely underlying mechanism for this patient’s abnormal bleeding?
  9. 9. + Abnormal Uterine Bleeding
  10. 10. + Definition Abnormal uterine bleeding refers to uterine bleeding outside of the parameters noted below :  Duration greater than eight days  Flow greater than 80 mL/cycle or subjective impression of heavier-than-normal flow (ie, more than six full pads or tampons per day)  Occur more frequently than every 24 days or less frequently than every 38 days  Intermenstrual bleeding or postcoital spotting  Absence of menses
  11. 11. +  Oligomenorrhea: menstruation occurring with intervals of more than 35 days  Polymenorrhea: menstruation occurring regularly with intervals of less than 21 days  Metrorrhagia: menstrual bleeding occurring at irregular intervals or bleeding between menstrual cycles  Menorrhagia: regular menstrual cycles with excessive flow (technically more than 80 mL of volume) or menstruation lasting more than 7 days  Menometrorrhagia: menstrual bleeding occurring at irregular intervals with excessive flow or duration
  12. 12. + Prevalence and Impact  In population-based studies, approximately 10 to 35 percent of women report having menorrhagia. [2-4]  Menorrhagia is a common reason for referral to a gynecologist .  Iron deficiency anemia develops in 21 to 67 percent of cases. [2]  Excessive and irregular bleeding can affect the quality of life. Absenteeism from work or school is bothersome to many women and bleeding may also interfere with sexual activity.
  13. 13. + Causes throughout Woman’s Lifetime
  14. 14. + Abnormal Uterine Bleeding Anovulatory Ovulatory
  15. 15. + Anovulatory Uterine Bleeding
  16. 16. + Pathophysiology  Estrogen breakthrough bleeding Anovulatory cycles have no corpus luteal formation. Progesterone is not produced.The endometrium continues to proliferate under the influence of unopposed estrogen.  Estrogen withdrawal bleeding This frequently occurs in women approaching the end of reproductive life. Ovarian follicles in these women secrete less estradiol. Fluctuating estradiol levels might lead to insufficient endometrial proliferation with irregular menstrual shedding.
  17. 17. + In anovulatory cycles, the follicular growth occurs with the stimulation from FSH; however, due to lack of LH surge, ovulation fails to occur. Ovary fails to secrete progesterone, although estrogen production continues Continuous, unopposed E stimulation of endometrium Endometrium becomes excessively vascular without stromal support Fragility and irregular endometrial bleeding
  18. 18. + Causes  In Adolescents Failure occurs secondary to delayed maturation of the hypothalamic-pituitary axis. Normal in 1-2 years after menarche.  Peri-menopausal Anovulatory bleeding in menopausal transition is related to declining ovarian follicular function.
  19. 19. +  Approximately 6 to 10 percent of women with anovulation have underlying polycystic ovary syndrome.  Uncontrolled diabetes mellitus, hypo- or hyperthyroidism, and hyperprolactinemia also may cause anovulation by interfering with the hypothalamic-pituitary-ovarian axis.  Antiepileptics (especially valproic acid [Depakene]) may cause weight gain, hyperandrogenism, and anovulation.  Use of typical antipsychotics (e.g., haloperidol), and some atypical antipsychotics (e.g. risperidone [Risperdal]) may contribute to anovulation by raising prolactin levels
  20. 20. + Evaluation  First, whom to evaluate ? Patients with irregular cycles who should be evaluated include a) adolescents with consistently more than three months between cycles or b) those with irregular cycles for more than three years [3]; c) women who are likely perimenopausal and have increased volume or duration of bleeding over baseline.
  21. 21. +  Initial evaluation of anovulatory uterine bleeding should include a) Confirm a uterine source of bleeding on physical examination b) Perform a pregnancy test. c) Assess whether the woman is pre- or postmenopausal. d) Evaluate the pattern, volume, and duration of blood loss.
  22. 22. + e) Assess ovulation: • Ovulation can generally be documented clinically, based on regular cyclic menses with molimina (eg, breast tenderness, bloating or pelvic discomfort, mood changes, thin vaginal discharge), or • can be confirmed by a serum progesterone level measured in the presumed luteal phase of the menstrual cycle; in most laboratories, a level of >4 ng/dL confirms ovulation. f) Perform laboratory testing for anemia g) Perform pelvic sonography to assess for uterine or other reproductive tract abnormalities that may contribute to uterine bleeding.
  23. 23. + g) ACOG recommends endometrial tissue assessment to rule out cancer in i. in adolescents and in women younger than 35 years with prolonged unopposed estrogen stimulation, ii. women 35 years or older with suspected anovulatory bleeding, and iii. women unresponsive to medical therapy
  24. 24. + Ovulatory Uterine Bleeding
  25. 25. +  Ovulatory abnormal uterine bleeding, or menorrhagia, presents as bleeding that occurs at normal, regular intervals but that is excessive in volume or duration.
  26. 26. + Etiologies  Bleeding disorder i. Factor deficiency ii. Leukemia iii. Platelet disorder iv. von Willebrand disease  Hypothyroidism  Liver disease, advanced  Structural lesions i. Fibroids ii. Polyps
  27. 27. + Bleeding disorders Suspected if : i. Menorrhagia since menarche ii. Family history of bleeding disorders iii. Personal history of 1 or more of the following: • Notable bruising without known injury • Bleeding of oral cavity or gastrointestinal tract without obvious lesion • Epistaxis greater than 10 minutes duration (possibly necessitating packing or cautery.
  28. 28. + CASE 2 A 27-year-old nulligravida female presents to your office for routine exam. Upon gynecological history, you discover that she has a 5-year history of oligomenorrhea, with only approximately two or three menses a year. She denies intercycle spotting or premenstrual symptoms. Her last menses was 3 months ago. Her blood pressure is 120/75 mmHg and her BMI is 34. Her physical exam reveals a moderate amount of facial hair and facial acne. Her pelvic examination is unremarkable
  29. 29. +  What condition do you suspect in this patient?  What are the treatment options ?
  30. 30. + Amenorrhea
  31. 31. + Definition and types  Primary amenorrhea is defined as the absence of menses at: i. age 16 in the presence of normal growth and secondary sexual characteristics,or ii. age 14, if no menses have occurred and there is an absence of secondary sexual characteristics.  Secondary amenorrhea is the absence of menses for three months in women with previously normal menstruation and for nine months in women with previous oligomenorrhea.
  32. 32. + Primary Amenorrhea
  33. 33. + Etiology of 1ry Amenorrhea Hypothalamic and Pituitary causes ① Functional hypothalamic amenorrhea. • Abnormal hypothalamic gonadotropin-releasing hormone (GnRH) secretion  decreased gonadotropin pulsations i. absent LH surges ii. absence of normal follicular development iii. anovulation. • Multiple factors may contribute to the pathogenesis of functional hypothalamic amenorrhea, including eating disorders (such as anorexia nervosa), exercise, and stress
  34. 34. + ② Congenital GnRH deficiency or idiopathic hypogonadotropic hypogonadism Kallmann’s Syndrome ? ③ Constitutional delay of puberty • characterized by both delayed adrenarche and gonadarche. ④ Hyperprolactinemia
  35. 35. + Ovarian Causes ① Gonadal dysgenesis ② Turner syndrome ③ Polycystic ovary syndrome ④ Premature ovarian failure • Loss of ovarian function before age of 40 • Idiopathic, but maybe related to a variant gene.
  36. 36. + Polycystic Ovarian Syndrome
  37. 37. + Congenital disorders of the uterus and vagina ①Müllerian agenesis causes approximately 15 percent of primary amenorrhea.[4] ②Imperforate hymen ③Transverse vaginal septum
  38. 38. + Diagnosis History  Detailed history of pubertal development  Family history of menarche, pubertal development  History of weight loss, stress, exercise (athletic activity)  Detailed dietary history  History of contraception,medications  History suggestive of CNS disease (eg, headaches, visual changes)  History of chronic illnesses (eg, Crohn disease)
  39. 39. + Physical examination  Height, weight, and growth charts  Breast development, pubic hair  Syndromic appearance (eg, short stature, webbed neck)  Visual fields, thorough neurologic examination, optic fundi  Evidence of hyperandrogenism (eg, acne, hirsutism, clitoromegaly)  Evidence of thyroid disease  Evidence of chronic illnesses  Evidence of pregnancy
  40. 40. + Evaluation Primary amenorrhea is evaluated most efficiently by focusing on the a) presence or absence of breast development (a marker of estrogen action and therefore function of the ovary), b) the presence or absence of the uterus (as determined by ultrasound, or in more complex cases by magnetic resonance imaging) c) and the follicle-stimulating hormone (FSH) level.
  41. 41. +Etiology of 2ry Amenorrhea  PREGNANCY is the most common cause of secondary amenorrhea.  Hypothalamic dysfunction ① Functional hypothalamic amenorrhea ② Inflammatory or infiltrative diseases (eg.Lymphoma) ③ Brain tumors (i.e. Craniopharyngioma) ④ Cranial irradiation ⑤ Pituitary stalk dissection or compression
  42. 42. + Pituitary dysfunction ① Hyperprolactinemia • Prolactinomas account for 20% of secondary amenorrhea • Account for 90% of secondary amenorrhea due to pituitary problems ② Pituitary tumors • Acromegaly • Corticotroph adenomas (i.e. Cushing’s disease) • Meningioma (of the sella), germinoma, glioma ③ Empty sella syndrome ④ Pituitary infarct/pituitary apoplexy • Sheehan’s syndrome
  43. 43. +  Ovarian dysfunction • Menopause: defined as 12 months of amenorrhea in a woman over age 45 in the absence of other biological or physiological causes. • Premature ovarian failure • Surgical removal • Polycystic ovarian disease
  44. 44. +  Uterine causes ① Acquired scarring of the endometrium • due to instrumentation e.g. Asherman’s Syndrome • due to infection eg. tuberculosis ① Cervical stenosis, often due to instrumentation
  45. 45. + Prolactin ≤ 100 ng per mL (100 mcg per L) Altered metabolism Liver failure Renal failure Ectopic production Bronchogenic (e.g., carcinoma) Breastfeeding Prolactin > 100 ng per mL Empty sella syndrome Pituitary adenoma
  46. 46. + CASE 3 A 15-year-old nulligravida female presents with her mother for evaluation of painful periods. Menarche was at age 14. Her periods are typically every 4–8 weeks and are very painful. She has missed 1–2 days of school with each menses because of the severe pain and has been suspended from the volleyball team because of missed practices. She denies intercourse. She has never had a pelvic examination. Her review of systems is otherwise negative.
  47. 47. +  What is the MOST likely etiology of her irregular cycles?  What is the etiology?  What is the best first-line treatment for this patient?
  48. 48. + Dysmenorrhea
  49. 49. + Definition and types  Dysmenorrhea is defined as difficult menstrual flow or painful menstruation. It is one of the most common gynecologic complaints in young women who present to clinicians.[5]  Dysmenorrhea can be divided into 2 broad categories: primary (spasmodic) and secondary (congestive).
  50. 50. + Primary dysmenorrhea  Primary dysmenorrhea is defined as menstrual pain that is not associated with macroscopic pelvic pathology.  It typically occurs in the first few years after menarche[6]and affects as many as 50% of postpubertal females.  In an epidemiologic study of an adolescent population (age range, 12-17 years), reported that dysmenorrhea had a prevalence of 59.7%. [7]
  51. 51. + Risk factors  Early age at menarche (< 12 years)  Nulliparity  Heavy or prolonged menstrual flow  Smoking  Positive family history  Obesity
  52. 52. + Pathophysiology  Current evidence suggests that the pathogenesis of primary dysmenorrhea is due to prostaglandin F2α (PGF2α), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium. [8]
  53. 53. + Treatment  Treatment is directed at providing relief from the cramping pelvic pain and associated symptoms .  Nonsteroidal anti-inflammatory drugs (NSAIDs) are the best- established initial therapy for dysmenorrhea. [9] They decrease menstrual pain by lowering prostaglandin F2α (PGF2α) levels in menstrual fluid.  Oral Contraceptives also relieve symptoms, particularly if contraception is required.
  54. 54. + Secondary dysmenorrhea  Less common than primary dysmenorrhea  It is associated with pelvic pathology  It tends to occur several years after the menarche  The woman may complain of a change in the timing and intensity of her pain  The pain may last throughout menstruation  The pain may be associated with discomfort before the onset of menstruation.
  55. 55. + Causes  Leiomyomata (fibroids)  PID  Tubo-ovarian abscess  Endometriosis
  56. 56. + Management  Treatment of secondary dysmenorrhea involves correction of the underlying organic cause.  Specific measures (medical or surgical) may be required to treat pelvic pathologic conditions (eg, endometriosis) and to ameliorate the associated dysmenorrhea
  57. 57. + Resources  [1] Caufriez A. Menstrual disorders in adolescence: pathophysiology and treatment. Horm Res 1991; 36:156.  [2]Côté I, Jacobs P, Cumming DC. Use of health services associated with increased menstrual loss in the United States. Am J Obstet Gynecol 2003; 188:343.  [3]Santer M, Warner P, Wyke S. A Scottish postal survey suggested that the prevailing clinical preoccupation with heavy periods does not reflect the epidemiology of reported symptoms and problems. J Clin Epidemiol 2005; 58:1206.  [4]Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract 2004; 54:359.  [3] Speroff L, Fritz MA. Amenorrhea. In: Clinical gynecologic endocrinology and infertility. 7th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins, 2005;401–64.  [4] ACOG Committee on Practice Bulletins—Gynecology. American College of Obstetricians and Gynecologists. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet. 2001;72(3):263–271.  [5] Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss--a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966; 45:320.  [6]Diaz A, Laufer MR, Breech LL; American Academy of Pediatrics Committee on Adolescence, American College of Obstetricians and Gynecologists Committee on Adolescent Health Care. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics. 2006;118(5):2245– 2250.  [[7] Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics. Nov 1981;68(5):661-4  [8] Willman EA, Collins WP, Clayton SG. Studies in the involvement of prostaglandins in uterine symptomatology and pathology. Br J Obstet Gynaecol. May 1976;83(5):337-41  [8] Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol 2003; 17:75.  [9] Proctor M, Farquhar C. Dysmenorrhoea. Clin Evid. 2002;(7):1639–53.
  58. 58. +