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Menstrual disorders

Menstrual disorders by HMC FM residents

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Menstrual disorders

  1. 1. Menstrual disorders diagnosis and management. Dr. Amir M. Hanafi PGY2 Under supervision of Dr. Um Kalthoum
  2. 2. Objectives • To review menstrual physiology • To know general approach to menstrual disorders • To know how to manage a case of Dysmenorrhea • To know how to manage a case of Menorrhagia • To know how to manage a case of Amenorrhea
  3. 3. Physiology • 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.
  4. 4. 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.
  5. 5. Terminology • 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 irregular intervals.
  6. 6. Terminology (contd.) • Intermenstrual bleeding — occurs between menses • Polymenorrhea — regular bleeding that occurs at an interval less than 24 days. • Premenstrual spotting — light bleeding preceding regular menses.
  7. 7. 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.
  8. 8. 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 medications? 7. Is there a personal or family history of a bleeding disorder?
  9. 9. Causes of anovulation
  10. 10. 6 – Drugs? Contd. • Drugs associated with AUB include: – hormonal contraceptives – postmenopausal hormone therapy – Anticonvulsants – Anticoagulants – Corticosteroids – psychopharmacologic agents
  11. 11. Chronic Menorrhagia • 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" .)
  12. 12. Amenorrhea • 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
  13. 13. causes
  14. 14. 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?
  15. 15. 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 prolactin)? – headaches, visual field defects, fatigue, or polyuria and polydipsia?
  16. 16. 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 Tanner staging) – A careful genital examination – Examination of the skin – Evaluation for the classic physical features of Turner syndrome
  17. 17. Evaluation
  18. 18. TREATMENT • 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.
  19. 19. Secondary amenorrhea