R2 diagnosis and management of menstrual disorders by HMC FM residents

1. Under supervision of
Dr O. BenGharbia
MRCGP, MD, MSc Sci
By Dr. Amir M Hanafi
PGY2

2. Objectives
 To review menstrual physiology
 To know how to manage a case of Menorrhagia
 To know how to manage a case of Dysmenorrhea
 To know how to manage a case of Amenorrhea

4. 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.

5. 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.

6. 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.

7. Case 1. Menorrhagia
A 43-year-old , got 2 children, LMP 21 days
ago, presents with heavy menstrual bleeding.
In the last 6 months there has been a change
with menses coming every 25-32 days, lasting
7-10 days and associated with cramps not
relieved by ibuprofen, passing clots.
Prior to 6 months ago her cycles came every
28-30 days, lasted for 6 days, and were
associated with cramps that were relieved by
ibuprofen.

8. Conti, case 1
 She denies dizziness, but complains of
feeling weak and fatigued.
 Her weight has not changed in the last year.
 She denies any bleeding disorders or
reproductive cancers in the family.
 She takes no daily medications and has no
other medical problems.
 She is divorced , non smoker and works as a
teacher.

9. Conti, case 1
 On examination;
 BP=130/88; P= 100; Ht=158 cm’; Wt=68 kg . She
appears pale.
 No (hirsuitism, acne,ecchymosis/ purpura, thyroid,
galactorrhea)
 Pelvic exam shows normal vulva, vagina and cervix:
normal size, not tender, mobile uterus;
 non-tender adnexae without palpable masses.
 What are the parameters of a normal menstrual
cycle?

10. The parameters of a normal
menstrual cycle
• Interval 21-35 days (Mean: 28 days)
• Duration: 2-7 days (Mean: 5 days)
• Volume: <80ml (Mean 35 ml)
• Composition: Non-clotting blood, endometrial debris

12. The possible etiologies could cause
this patient’s bleeding?
 PALM-COEIN is an acronym that was published in
2011 by the International Federation of Gynecology
and Obstetrics at 2011.
 Was created for the purpose of establishing a
universally accepted nomenclature to describe
uterine bleeding abnormalities

13. The possible etiologies could cause
this patient’s bleeding
 • PALM-Structure Causes
 Polyp
 Adenomyosis
 Leiomyoma
 Malignancy and Hyperplasia
 COEIN-Non-structural Causes
 Coagulopathy
 Ovulatory Dysfunction
 Endometrial
 Iatrogenic
 Not Yet Classified

14. What are the appropriate lab tests
that should be ordered in this
patient?
 • CBC, TSH, Prolactin
 • Pregnancy Test
 • Endometrial Biopsy
 • Pelvic Ultrasound

15. Results of investigation
 Labs show Hgb: 9 gr/100 dl., HCT: 27%, HCG:
negative, , TSH and Prolactin are within normal
limits.
 Pelvic Ultrasound: heterogeneous myometrium,
endometrial lining 1.4cm with, normal ovaries.
 Endometrial biopsy: normal secretory
endometrium.
What further tests would you order
based on the following results?

16. Further tests would you order?
Fluid-enhanced sonohysterogram
Hysterosalpingogram
Diagnostic hysteroscopy

17. Endometrial evaluation of
menorrhagia
Endometrial Biopsy Sensitivity -91%
False positive rate -
2%
Office procedure, well tolerated, anesthesia and
cervical dilation usually not required
Transvaginal
Ultrasound (TVS)
Sensitivity -88% Good visualization of fibroids; may fail to identify
other intracavitary abnormalities
like polyps
Saline Infusion
Sonohysterosc-
Opy (SIS)
Sensitvity -97%
NPV -94%
Procedure of choice (detection and cost).
Sterile isotonic fluid is instilled into the uterus
under continuous visualization of
endometrium with TVS
Hysteroscopy Sensitivity -100% Highest cost. Better in pre-menopausal women.
Does not reduce hysterectomy rate even without
intra cavitary path. Used as gold standard for
other procedures

18. How can you tell if this patient is
having ovulatory cycles?
 History consistent with ovulatory cycles (regular,
presence of cycle)
 Timed (luteal phase) endometrial biopsy- is it
secretory?
 LH surge kits (ovulation prediction kits) detect LH
surge in urine which follows LH surge in serum but
occurs before ovulation
 Basal body temperature chart with small temperature
increase (0.5 degrees) after ovulation
 Day 21 serum progesterone level.

19. Menorrhagia, medical management
 NSAID’s, 30% 1st line, 5 days, decrease prostaglandins
 Anti fibrinolyltic (transamine) 50% decrease in blood
flow)
 OCP’s, esp. if contraception desired, up to 60% dec. supp. HP axis
 Oral continous progestins (day 5 to 26), most prescribed,
 Levonorgestrel IUD (Mirena), High satisfaction rate
 GnRH agonists, Inhibit FSH and LH release– hypogonadism, bone
 Conjugated estrogens for acute bleeding
 Danazol, androgenic steroid, amenorrhea in 4-6 weeks,
androgenic side effects
 Other treatments as indicated e.g. DDAVP for coagulation
defects
 Combination can be used

20. Menorrhagia, surgical management
Surgical
Ablation
Myomectomy
Hysterect-
omy
? D & C
polypectomy

21. Menorrhagia, management
summary
 Tailor treatment to individual patient.
 Consider patients age, coexisting medical
diseases, FH, desire for fertility, cost of rx
and adverse effects
 Surgical management reserved for organic
causes (e.g fibroids) or when medical
management fails to alleviate symptoms

22. Case 2; dysmenorrhea
 A 14-year-old female comes to the clinic,
complaining of severe dysmenorrhea (painful
periods) for the past six months. She began
menstruating 10 months ago with her first two
periods occurring about 2 months apart
without pain or any other symptoms.
 Since then, she menstruates every 28 days and
also notices nausea, diarrhea and headaches
during her periods. The pain has gotten so bad
for 3 days each month that she often misses
school.

23. Case 2 conti,
 She is involved in sports and after school
programs, and you think it is unlikely that
she is pretending to have dysmenorrhea to
get out of school. She denies use of drugs .
She says that she gets partial relief by using
2-3 ibuprofen , two or three times a day
during her period.
 The review of systems, past medical history
and social history are noncontributory. The
patient’s mother has endometriosis.

24. Physical exam:
 The patient’s general and systemic
examination were unremarkable .
 Pelvic exam not done, a rectal exam
showing a normal size non-tender uterus,
which is mobile and anteflexed. There are
no nodules on the back of the uterus, and
there are no adnexal masses or tenderness.
 Laboratory:
 Urinalysis is negative for blood, nitrites and
leukocytes.

25. Discussion Questions
 What is the differential diagnosis and most
likely diagnosis?
 What additional evaluation is needed?
 How would you manage the possible
diagnoses ?

26. What is the differential diagnosis
and most likely diagnosis?
 Primary dysmenorrhea is most likely; based on the
onset of pain and associated systemic symptoms, as
well as the partial response to NSAIDs
 • Secondary dysmenorrhea with underlying
endometriosis is less likely; based on the normal
physical examination, and the short interval since
menarche.
 The patient may have an increased risk of
endometriosis due to her mother’s history. Most
causes of secondary dysmenorrhea increase with age
such as structural abnormalities ( i.e. leiomyomata,
polyps).

27. What additional evaluation is
needed?
 A careful history is all that is needed in most cases of
primary dysmenorrhea.
 No additional evaluation is needed for the
presumptive diagnosis of primary dysmenorrhea.
 • However, if appropriate treatment fails to relieve
symptoms within 3 months, pelvic exam and
additional evaluation (such as ultrasound,
hysteroscopy or laparoscopy) is needed to rule out a
secondary cause such as endometriosis.

28. How would you manage the diagnoses
of primary dysmenorrhea?
 NSAIDs are first line treatment
 Combination hormonal contraceptives (pills, or patch) or
progesterone-only contraceptive (progesterone injection or
implant) provide effective contraception and improve
symptoms of dysmenorrhea.
 NSAIDs are prostaglandin-synthetase inhibitors,
 While hormonal contraceptives inhibit ovulation and
progesterone stimulation of prostaglandin production.
 Within three months of starting hormonal contraceptives,
90% of women experience improvement.

29. Case 3; Amenorrhea
A 26-year-old seen at clinic complaining of no periods
for 9 months. She got 2 children, ages are 5 and 3 years.
She breastfed her youngest for 1 year, menses returned
right after she stopped, and were monthly and normal
until 9 months ago.
She is not using any contraception or any other
medication.
She feels very fatigued, has frequent headaches and has
had trouble losing weight.
She has no history of abnormal Paps or STI’s.
She is married and works from home as a computer
consultant.

30. Examination
 BP= 120/80, P= 64, Ht=164cm , Wt= 61 kg .
 She appears tired but in no distress.
 Breasts show scant bilateral milky white discharge
with manual stimulation. Breast exam reveals no
masses, dimpling or retraction.
 Examination otherwise normal, including pelvic exam.
 HCG is negative.

31. Discussion Questions:
 1. Does this patient have primary amenorrhea,
secondary amenorrhea or oligomenorrhea?
 2. What is the differential diagnosis for this disorder?
 3. What additional studies are needed?
 4. Consider that this patient has a prolactin level of
above 130. The test when repeated with the patient
fasting is 100. What is your next step? (normal range
<22)
 5. If the patient had a withdraw bleed to a
progestational challenge and a normal TSH and
prolactin, what would be the most likely diagnosis,
and what is first line treatment, and long term
concern if untreated.

32. Does this patient have primary or
secondary amenorrhea, or
oligomenorrhea?
 Primary amenorrhea definition: no period
age 14 without secondary sex characteristics,
age 16 with secondary sex characteristics.
 Secondary amenorrhea definition: 6
months of amenorrhea after a history of
normal menses.
 Oligomenorrhea: menstrual interval >35
days but less than 6 months.

33. What is the differential diagnosis
for this disorder?
 Pregnancy
 •Hypothalamic--‐Pituitary Dysfunction
(Pituitary adenoma, sever Hypothyroidism,
Medications, brain tumor, chronic illness,
excessive exercise & stress,)
 Ovarian Dysfunction (Premature ovarian failure)
 Genital Outflow Tract Abnormalities
 Anovulation (Polycystic ovarian syndrome&
Thyroid dysfunction)

34. What additional studies are
needed?
CBC, pregnancy test, TSH, prolactin
level, FSH,
Progesterone challenge can distinguish
anovulation hypogondism versus a low
estrogen or pituitary/hypothalamic
etiology.

35. Results
 Prolactin 12 ng/ml (normal range <22) & TSH 1.2
uIU/ml (normal range: 0.4-4.0)
 • Progestin challenge is negative consistent with
hypogonadism. •
 Next step in hypogonadism is FSH 80 uIU/ml.
 Consistent with premature ovarian insufficiency
(POI)
 Treat POI with HRT; replace estrogen in order to
protect against osteoporosis (and progestin to
protect the uterus

36. Consider that this patient has a
prolactin level of above 130. when
repeated with the patient fasting is
100. What is your next step?
 Males: 2 - 18 ng/mL
 Nonpregnant females: 2 - 29 ng/mL
 Pregnant women: 10 - 209 ng/mL

37. Pituitary MRI
Treat with dopamine agonist like
bromocriptine or surgical option.

39. If the patient had a withdraw bleed to a
progestational challenge and a normal
TSH and prolactin, what would be the
most likely diagnosis, first line
treatment, and long term concern if
untreated?

40. Polycystic ovarian syndrome
• If not wanting to conceive, COCP are best first line
treatment. If wanting to conceive, ovulation
induction with clomiphene citrate.
• Long term the patient is at risk for endometrial
hyperplasia / uterine cancer if not treated with
progestins regularly.
Patient is also at increased risk of diabetes and high
cholesterol.

42. Case 4; postmenopausal bleeding
 A 66 year-old nulliparous women who
underwent menopause at 55 years complains
of a 2- week history of vaginal bleeding
 Prior to menopause she had irregular menses.
She denies the use of oestrogen replacement
therapy
 her medical history is significant for diabetes
mellitus & hypertension controlled with an
oral hypoglycaemic & antihypertensive agent.

43. On examination;
 84 kg weight, height 158cm
 BP 150/90 mmHg and temp 37.1 c
 The heart and lung exam are normal The abdomen
is obese and no masses are palpated
 the external genitalia appear normal
 The uterus normal size with out adnexal masses

44. Discussion Questions
 What is the next step?
Perform an endometrial biopsy
 What is your concern ?
Concern ; Endometrial Cancer
 What is the risk factor for endometrial
cancer?

45.  She undergoes endometrial sampling , and is
diagnosed with endometrial cancer
 Which of the following is a risk factor for
endometrial cancer ?

46. a risk factor for endometrial cancer ?
 endogenous risk factors
 increasing age
 obesity and physical inactivity
 low parity or infertility
 diabetes mellitus
 hypertension
 early menarche and late menopause
 polycystic ovarian syndrome
 family history
 lynch syndrome (hereditary nonpolyposis colorectal cancer)
 oestrogen secreting tumours (granulosa or thecal cell tumours of ovary)
 history of breast cancer
 immunodeficiency
 exogenous risk factors
 unopposed oestrogen only hormone replacement therapy
 tamoxifen therapy
 dietary factors
 previous radiotherapy

47. Thank You