diagnosis and management.
Dr. Amir M. Hanafi
Under supervision of Dr. Um Kalthoum
• To review menstrual physiology
• To know general approach to menstrual
• To know how to manage a case of
• To know how to manage a case of
• To know how to manage a case of
• By convention, the first day of menses represents
the first day of the cycle (day 1). The cycle is then
divided into two phases: follicular and luteal.
• The follicular phase begins with the onset of
menses and ends on the day of the luteinizing
hormone (LH) surge.
• The luteal phase begins on the day of the LH
surge and ends at the onset of the next menses.
Fact check: “Normal” menses
• The normal menstrual cycle length is from 24 to 35 days
• lasting from two to seven days
• flowing less than 80 mL per cycle (average normal amount
of menstrual blood loss is 30 to 40 mL per cycle).
• There is significantly more cycle variability for the first five
to seven years after menarche and for the last ten years
before complete cessation of menses.
• Predictable cyclic menses reflect regular ovulation
• cycles that vary in length by more than 10 days from one
cycle to the next are likely to be anovulatory.
• Clinical signs of ovulation include breast tenderness,
bloating or pelvic discomfort, mood changes, and thin
vaginal discharge at mid-cycle.
• Dysfunctional uterine bleeding — excessive
noncyclic endometrial bleeding unrelated to
anatomical lesions, usually anovulatory bleeding.
• Menorrhagia —It is technically defined as blood
loss greater than 80 mL per cycle and/or menstrual
periods lasting longer than seven days
• Metrorrhagia — light bleeding from the uterus at
• Intermenstrual bleeding — occurs between
• Polymenorrhea — regular bleeding that
occurs at an interval less than 24 days.
• Premenstrual spotting — light bleeding
preceding regular menses.
Terminology (contd. 2)
• Amenorrhea — absence of bleeding for at
least three usual cycle lengths.
• Oligomenorrhea — bleeding that occurs at an
interval greater than 35 days or less than 9
cycles per year.
• Dysmenorrhea — Primary dysmenorrhea
refers to recurrent, crampy lower abdominal
pain that occurs during menstruation in the
absence of pelvic pathology.
Hx and complaint analysis
1. Where is the bleeding coming from?
2. What is the woman's age? Is she pregnant?
3. What is her normal menstrual cycle like? Are there
symptoms of ovulation?
4. What is the nature of the abnormal bleeding
(frequency, duration, volume)? When does it occur?
5. Are there any associated symptoms?
6. Does she have a systemic illness or take any
7. Is there a personal or family history of a bleeding
• INTRODUCTION — Chronic heavy or prolonged uterine bleeding is a common
gynecologic problem. Such bleeding may be ovulatory or anovulatory. Chronic
heavy or prolonged uterine bleeding can result in anemia, interfere with daily
activities, and raise concerns about uterine cancer. Most women with heavy or
prolonged uterine bleeding require medical attention, but can be managed on a
nonacute, outpatient basis. Occasionally, uterine bleeding is severe enough to
necessitate immediate medical evaluation and treatment.
• Chronic heavy or prolonged uterine bleeding in nonpregnant premenopausal
women will be reviewed here. Uterine bleeding that requires urgent treatment,
the general evaluation of abnormal uterine bleeding, menorrhagia in patients with
von Willebrand disease, and uterine bleeding in pregnancy are discussed
separately. (See "Managing an episode of severe or prolonged uterine
bleeding" and "Terminology and evaluation of abnormal uterine bleeding in
premenopausal women" and "Treatment of von Willebrand disease", section on
'Treatment of excessive menstrual bleeding' and "Overview of the etiology and
evaluation of vaginal bleeding in pregnant women" .)
• Primary amenorrhea is defined as the absence
of menses at age 15 in the presence of normal
growth and secondary sexual characteristics.
• Secondary amenorrhea is absence of menses
for more than three cycles or six months in
women who previously had menses
Approach to primary amenorrhea
Step 1: History
• the following questions should be asked of a
woman with primary amenorrhea:
– Has she completed other stages of puberty
– Is there a family history?
– Turner syndrome ?
– Was neonatal and childhood health normal
– Are there any symptoms of virilization?
Step 1: History
– Lately, has there been stress, change in weight,
diet, or exercise habits, or illness?
– Is she taking any drugs?
– Is there galactorrhea (suggestive of excess
– headaches, visual field defects, fatigue, or
polyuria and polydipsia?
Step 2: Physical examination
• The physical examination in a woman with
primary amenorrhea should begin with:
– An evaluation of pubertal development
– An assessment of breast development (eg, by
– A careful genital examination
– Examination of the skin
– Evaluation for the classic physical features of
• Treatment of primary amenorrhea is directed at correcting the underlying pathology (if possible), helping the woman to achieve fertility (if desired), and prevention of complications of
the disease process (eg, estrogen replacement to prevent osteoporosis).
• All women with primary amenorrhea should be counseled regarding its cause, treatment, and their reproductive potential. Psychological counseling is particularly important in patients
with absent müllerian structures or a Y chromosome.
• Surgery may be required in patients with either congenital anatomic lesions or Y chromosome material. The etiology of the primary amenorrhea will determine the type of surgical
procedure required. As an example, surgical correction of a vaginal outlet obstruction is necessary as soon as the diagnosis is made after menarche to allow passage of menstrual blood.
Creation of a neovagina for patients with müllerian failure is usually delayed until the women are emotionally mature and ready to participate in the postoperative care required to
maintain vaginal patency.
In those patients in whom Y chromosome material is found, gonadectomy should be performed to prevent the development of gonadal neoplasia [ 12-14 ]. However, gonadectomy
should be delayed until after puberty in patients with complete androgen insensitivity syndrome. These patients have a normal pubertal growth spurt and feminize at the time of
expected puberty; tumors do not usually develop until after this time. (See "Diagnosis and treatment of disorders of the androgen receptor" .)
• Women with primary ovarian insufficiency (premature ovarian failure) should be counseled regarding the benefits and risks of postmenopausal hormone therapy. For young women, the
benefits and risks of postmenopausal hormone therapy are markedly different than for a 60-year-old woman. In general, in women of reproductive age with hypoestrogenism, the
benefits of hormone replacement outweigh the risks of myocardial infarction, stroke, and breast cancer. (See "Postmenopausal hormone therapy: Benefits and risks" and "Management
of spontaneous primary ovarian insufficiency (premature ovarian failure)" .)
• In women with PCOS, treatment of hyperandrogenism is directed toward achieving the woman's goal (eg, relief of hirsutism, resumption of menses, fertility) and preventing the long-
term consequences of PCOS (eg, endometrial hyperplasia, obesity, and metabolic defects). (See "Treatment of polycystic ovary syndrome in adults" .)
• In most cases, functional hypothalamic amenorrhea can be reversed by weight gain, reduction in the intensity of exercise, or resolution of illness or emotional stress. For women who
want to continue to exercise, estrogen-progestin replacement therapy should be given to those not seeking fertility to prevent osteoporosis and heart disease. Women who want to
become pregnant can be treated with exogenous gonadotropins or pulsatile GnRH, but increased caloric intake is simpler and clearly preferable. Furthermore, if a woman does not eat
enough to have regular cycles and normal fertility, her nutrient intake during a hormonally-induced pregnancy is likely to be inadequate for normal fetal growth and development.
(See "Amenorrhea and infertility associated with exercise" .)
• The same considerations apply to women with hypothalamic or pituitary dysfunction that is not reversible (eg, congenital GnRH deficiency). For women who want to become pregnant,
either exogenous gonadotropins or pulsatile GnRH can be given. In a retrospective comparative study, pulsatile GnRH produced a higher rate of conception (96 versus 72 percent) and a
lower rate of higher order multiple gestations [ 15 ]. (See "Congenital gonadotropin-releasing hormone deficiency (idiopathic hypogonadotropic hypogonadism)" .)
• Advances in assisted reproductive technologies now make it possible for many women with primary amenorrhea to participate in reproduction. For women with gonadal dysgenesis, the
use of donor oocytes and their partners' sperm with IVF allow the women to carry a pregnancy in their own uterus. (See "Oocyte donation for assisted reproduction" .) For women with
an absent uterus, use of their own oocytes in IVF and transfer of their embryos to a gestational carrier can allow these women to have genetically related children.