presentation on MENSTRUAL DISORDERS

MENSTRUAL DISORDERS
Dr. Adnan Butt
MCPS Family Medicine, MRCGP [international]

Objectives
• To understand the physiology of normal menstrual cycle
• To know the types of abnormal uterine bleeding

Normal menstrual cycle
• The average menstrual cycle is of 28 days, but anything between 24
to 35 days is common
• It consists of four phases: menstruation, follicular phase, ovulation,
luteal phase

Normal menstrual cycle
• The average menstrual cycle is of 28 days, but anything between 24
to 35 days is common
• It consists of four phases: menstruation, follicular phase, ovulation,
luteal phase
• Periods can last from 1-8 days
• Average blood loss is 20-60 ml

Premenstrual syndrome
• PMT: symptoms/bodily changes in the days/weeks leading up to the
periods, that resolve or decrease significantly during the period
• PMS: if occurring on regular basis and are severe enough to interfere
with the quality of life

• >95% women have some sort of symptoms; <20% seek help;
debilitating symptoms occur in 5%

• >95% women have some sort of symptoms; <20% seek help;
debilitating symptoms occur in 5%
• Though to result from hormonal changes that occur after ovulation
affecting neurotransmitters in the brain

• Symptoms include:
Psychological: mood swings, irritability, nervous tension ( if severe, termed
as PMDD)
Physical: abdominal bloating, weight gain, breast tenderness, headache
Behavioral: decrease visuospatial and cognitive ability, increase in accidents

• Management aims to alleviate the symptoms. Usually symptoms
return when the treatment is stopped

Keep a diary for >2m

Keep a diary for >2m
For mild/moderate symptoms, try lifestyle/dietary modifications first like
loose clothing, adequate sleep, high-intensity exercise, regular small frequent
meals (avoid sweet snacks, caffeine, alcohol, fat, salt; eat plenty of
fruits/vegetables and complex carbohydrates), decrease fluid intake, eat
diuretic foods (strawberries, watermelon, prunes, figs)

Complimentary therapies: vitamin B-6 (10mg/day), magnesium supplements,
calcium supplements, chaste tree berry (can cause menstrual irregularity), oil
of evening primrose (can cause fits in epileptics)

CBT-effects are slower but long-lasting

COC is first-line. Low-dose estrogen is second line (100mcg estradiol patches.
Combine with a progestogen from day 17-28)

Combine with a progestogen from day 17-28).
SSRI are first-line (can be given continuously or just on days 15-28)

Diuretics and NSAID are also helpful

hysterectomy+oophorectomy is curative (most women require
HRT/testosterone replacement afterwards)

hysterectomy+oophorectomy is curative (most women require
HRT/testosterone replacement afterwards)
Estrogen patches & GnRH analogues for specialists only!

Abnormal uterine bleeding
• Oligomenorrhea
• Polymenorrhea
• Menorrhagia
• Metorrhagia
• Menometorrhagia
• Post-coital bleeding
• Inter-menstrual bleeding
• Amenorrhea

• Anovulatory
• Ovulatory

• Anovulatory uterine bleeding:

6%-15% of US women
Unopposed estrogen
Endometrium continues to proliferate
No luteal phase
Variable and erratic cycle length
Common around menarche, in the perimenopause, and in women with PCOS

Other causes include problems that disrupt H-P-O axis like hypo or
hyperthyroidism, hyperprolactinemia, DM, obesity, eating disorders,
aggressive exercises, stress, etc.

Other causes include problems that disrupt H-P-O axis like hypo or
hyperthyroidism, hyperprolactinemia, DM, obesity, eating disorders,
aggressive exercises, stress, etc.
Premature ovarian failure, Cushing syndrome, CAH, adrenal insufficiency,
hypothalamic tumors, hypothalamic trauma, hypothalamic radiation, Hand-
Schuller-Christian disease, pituitary trauma, pituitary radiation, Sheehan
syndrome, empty sella syndrome, pituitary apoplexy

Assessment includes pregnancy test, FSH, LH, estradiol, progesterone (mid-
luteal), TSH, prolactin, OGTT, cortisol, testosterone, DHEAS, 17-
hydroxyprogesterone

hydroxyprogesterone
CBC, RFT, LFT, antinuclear antibodies, RF, ESR, C-reactive protein, thyroid
antibodies
Ultrasound, CT (adrenals), MRI (pituitary), DEXA, nuclear thyroid scan

hydroxyprogesterone
CBC, RFT, LFT, antinuclear antibodies, RF, ESR, C-reactive protein, thyroid
antibodies
Ultrasound, CT (adrenals), MRI (pituitary), DEXA, nuclear thyroid scan
Endometrial biopsy

Treatment consists of holistic approach, multi-tiered approach

Heavy bleeding can be controlled by oral or intravenous estrogen. PREMARIN
25 mg IV 4 hourly. If no response in 24 hours, D&C should be done
If normal bleeding, high dose OCP (3 pills/day for 7 days) followed by regular
dose of OCP for 3 months
Focus on withdrawal bleed with progesterone

Heavy bleeding can be controlled by oral or intravenous estrogen. PREMARIN
25 mg IV 4 hourly. If no response in 24 hours, D&C should be done
If normal bleeding, high dose OCP (3 pills/day for 7 days) followed by regular
dose of OCP for 3 months
Focus on withdrawal bleed with progesterone
Treat the cause: clomiphene 50mg od; levothyroxine 25mcg od;
norethindrone/ethinylestradiol 0.5mg/35mcg od; medroxyprogesterone 5-
10mg/day; Glucophage 500mg od; fludrocortisone 0.1mg/day; bromocriptine
1.5-2.5mg/day

Surgical options include resection of pituitary tumors, exploratory laparotomy
for ovarian or adrenal neoplasm, D&C or hysterectomy for profound anemia,
bariatric surgery for obesity, etc.
Ovarian drilling and ovarian wedge resection for PCOS with efficacy of 80%

• Ovulatory uterine bleeding:

Bleeding occurs at normal regular intervals
But heavy (menorrhagia)

Bleeding occurs at normal regular intervals
But heavy (menorrhagia)
Causes include DUB (50%), congenital uterine abnormality, pelvic infection,
fibroids, endometriosis, endometrial/cervical polyp, endometrial carcinoma,
presence of IUCD, bleeding disorders, hormone-producing tumors

Dysfunctional uterine bleeding (DUB)

Dysfunctional uterine bleeding (DUB)
Excessive menstrual loss in the absence of any detectable abnormality
Symptoms suggestive of other pathology: irregular bleeding, sudden change in blood
loss, post-coital bleeding, dyspareunia, pelvic pain, premenstrual pain
Risk factors for endometrial carcinoma: age (very uncommon less than 40 years),
tamoxifen, unopposed estrogen treatment, PCOS, obesity

Fibroids (uterine leiomyoma)

Benign tumors of smooth muscle of myometrium
Affects 1 in 5 women
Often multiple
Named by location: intramural, submucosal, cervical, etc.
Risk factors are nulliparity, obesity, FH of fibroids, African origin

Benign tumors of smooth muscle of myometrium
Affects 1 in 5 women
Often multiple
Named by location: intramural, submucosal, cervical, etc.
Risk factors are nulliparity, obesity, FH of fibroids, African origin
Estrogen dependent, so regress post-menopause!

Usually asymptomatic. May cause pelvic pressure or backache, menorrhagia, pain (pain,
fever, local tenderness-called red degeneration may occur in pregnancy), urinary
symptoms, infertility (natural IUCD), etc.
Diagnosis is by Pelvic ultrasound; calcified fibrosis may be an incidental finding on x-ray

Usually asymptomatic. May cause pelvic pressure or backache, menorrhagia, pain (pain,
fever, local tenderness-called red degeneration may occur in pregnancy), urinary
symptoms, infertility (natural IUCD), etc.
Diagnosis is by Pelvic ultrasound; calcified fibrosis may be an incidental finding on x-ray
Medical treatment includes CHC or IUS (decreases menstrual loss), GnRH analogues
(maximum use is 6m due to risk of osteopenia), selective progesterone receptor
modulator like asoprisnil (causes shrinkage)
Surgical treatment includes uterine artery embolization, myomectomy (removal of
fibroids only), hysteroscopic resection, hysterectomy

Endometriosis

Endometriosis
Presence of histologically similar tissue to endometrium OUTSIDE the uterus
Most commonly found in pelvis
Affects 10%-15% of women
Risk factors are heavy periods, frequent cycles

Endometriosis
3 cardinal symptoms: Dysmenorrhea, Dyspareunia, Pelvic pain. Also causes menorrhagia,
infertility, bowel/bladder symptoms

Endometriosis
Investigations include STI screen (for sexually active women), transvaginal U/S, MRI,
laparoscopy (30%-50% diagnostic laparoscopies are negative)

Endometriosis
Investigations include STI screen (for sexually active women), transvaginal U/S, MRI,
laparoscopy (30%-50% diagnostic laparoscopies are negative)
Oral contraceptives and pregnancy are protective!

Endometriosis
Management of infertility includes referral to specialist for reconstructive surgery or IVF
(if tubal damage) or laparoscopic ablation (if no tubal damage)

Endometriosis
Pain and bleeding can be controlled by NSAID, IUS, progestogen (norethisterone 10-
15mg/day for 4-6m-if spotting occurs, increase the dose to 20-25mg/day and stop once
bleeding has ceased) or continuous CHC (3-4 packets without a break, then 7d break)

Endometriosis
Specialist treatment includes Gestrinone and GnRH agonists (e.g. goserelin) +/- HRT. Side
effects can be troublesome

Endometriosis
Surgical options include laparotomy with ablation of lesions and division of adhesions,
tubal surgery, hysterectomy

Endometriosis
Surgical options include laparotomy with ablation of lesions and division of adhesions,
tubal surgery, hysterectomy
15%-20% recurrence rate. If relapse in <6m, treatment has failed and try alternative
method. If relapse in >6m, consider the condition to have relapsed and repeat treatment

• Amenorrhea

• Amenorrhea
Primary amenorrhea
Secondary amenorrhea

• Amenorrhea

• Amenorrhea
No menstruation by age 16
When growth and sexual development is normal

• Amenorrhea
Causes include outflow abnormalities (Mullerian agenesis, transverse vaginal septum,
androgen insensitivity, imperforate hymen), ovarian disorders (PCOS, Turner’s
syndrome), pituitary disorders (prolactinoma), hypothalamic disorders (Kallman’s
syndrome)

• Amenorrhea
Causes include outflow abnormalities (Mullerian agenesis, transverse vaginal septum,
androgen insensitivity, imperforate hymen), ovarian disorders (PCOS, Turner’s
syndrome), pituitary disorders (prolactinoma), hypothalamic disorders (Kallman’s
syndrome)
Specialist referral

• Amenorrhea
Mullerian agenesis

• Amenorrhea
Present in about 1 in 4500 women
30% of these patients have associated renal anomalies, most commonly unilateral renal
agenesis

• Amenorrhea
agenesis
U/S and MRI are helpful in diagnosing other associated anomalies, especially before surgery

• Amenorrhea
agenesis
Vaginal reconstruction is performed with repeated operations; strictures, stenosis, fistula
formation is very common

MRKH syndrome (Mayer-Rokitansky-Kuster-Hauser syndrome)

• Amenorrhea
Imperforate hymen

• Amenorrhea
Most common genital outflow tract anomaly

• Amenorrhea

• Amenorrhea
Repair can be done at any age; although repair is facilitated when estrogen stimulation is
present

MRI showing fluid collection in uterus and proximal vagina (distal vaginal atresia misdiagnosed as imperforate hymen)

Imperforate hymen with pyocolpos

• Amenorrhea
Androgen insensitivity syndrome

• Amenorrhea
X-linked genetic disorder
Affects 1 in 62000 male births
Androgen receptor abnormalities

• Amenorrhea
Genotypically male (46XY) but phenotypically female
External genitalia are female in CAIS and ambiguous in PAIS
Breast development occurs and female contours form, but little or no pubic or axillary hair

• Amenorrhea
Genotypically male (46XY) but phenotypically female
External genitalia are female in CAIS and ambiguous in PAIS
Breast development occurs and female contours form, but little or no pubic or axillary hair
Specialist treatment includes removal of testes and estrogen replacement to complete
secondary sexual development

Primary amenorrhea-Mcgraw Hill; AAFP

• Amenorrhea

• Amenorrhea
Absence of menses for 3 or more months in previously menstruating women

• Amenorrhea
Causes include cerebral problems (stress, starvation, anorexia, neoplasm, exercise,
psychotropic drugs), H-P problems (prolactinoma, post-surgery), thyroid problems
(hypo/hyperthyroidism), adrenal problems (Cushing’s syndrome, tumors), ovarian
problems (menopause, PCOS), uterine/vaginal problems (pregnancy, Asherman’s
syndrome)

• Amenorrhea
syndrome)
Always consider the possibility of pregnancy!

• Amenorrhea
syndrome)
Always consider the possibility of pregnancy!
For young girls, replace vaginal/pelvic examination with per-abdominal pelvic U/S

Secondary amenorrhea-Mcgraw Hill

• Amenorrhea
Asherman’s syndrome

• Amenorrhea
Rare; secondary to uterine procedures (D&C, myomectomy, C-sections, hysteroscopy) or
infection (endometritis, genital tuberculosis)
Fibrous tissue/scar tissue inside the uterine cavity

• Amenorrhea
Symptoms include hypomenorrhea or amenorrhea, pelvic pain
Complications include infertility, recurrent miscarriages, preterm labor, IUGR, placenta previa

• Amenorrhea
Diagnostic modalities include bimanual pelvic examination, hysteroscopy, HSG, MRI

• Amenorrhea
Ideally, prevention is the best solution! Medical evacuation (misoprostol) of the uterus should
be sought first, avoiding any instrumentation; D&C could be performed under U/S guidance

• Amenorrhea
Ideally, prevention is the best solution! Medical evacuation (misoprostol) of the uterus should
be sought first, avoiding any instrumentation; D&C could be performed under U/S guidance
No evidence to suggest that suction D&C is less likely to result in adhesions

• Amenorrhea
The management consists of treatment (D&C, hysteroscopy, hysterectomy), re-adhesion
prevention (intrauterine device, uterine balloon stent, foley’s catheter, anti-adhesion
barriers), restoring normal endometrium (hormonal treatment), post-operative assessment
(repeat surgery, diagnostic hysteroscopy, U/S)

• Amenorrhea
The management consists of treatment (D&C, hysteroscopy, hysterectomy), re-adhesion
prevention (intrauterine device, uterine balloon stent, foley’s catheter, anti-adhesion
barriers), restoring normal endometrium (hormonal treatment), post-operative assessment
(repeat surgery, diagnostic hysteroscopy, U/S)
Even in women who conceive after treatment, strict surveillance should be carried out for the
high risk of placental anomalies and effort should be devoted to prevention

• Dysmenorrhea

• Dysmenorrhea
Painful menstruation
>50% pre-menopausal women
1 in 10 women experience significant interference in their lifestyles
Can be divided into primary and secondary dysmenorrhea

• Dysmenorrhea
Primary dysmenorrhea

• Dysmenorrhea
No underlying pelvic pathology
Possibly due to release of PG-F2, a potent myometrial stimulant & vasoconstrictor
Tends to start 6-12m after menarche when ovulatory cycles are established

• Dysmenorrhea
Presents with lower abdominal pain +/- backache
Especially in the first 1-2d of each period
May be associated with GI disturbance

• Dysmenorrhea
Full abdominal and pelvic examination required

• Dysmenorrhea
Young women <20y with no other symptoms do not require examination unless
pathology is suspected!

• Dysmenorrhea
Young women <20y with no other symptoms do not require examination unless
pathology is suspected!
 10%-20% do not respond-consider a missed cause!

• Dysmenorrhea
Treatment consists of topical heat therapy, NSAID (effective in 80%-90%; start when
bleeding starts), CHC (effective in 80%-90%)

• Dysmenorrhea
Limited data: low-fat vegetarian diet, pyridoxine, magnesium, vitamin-E, acupuncture,
acupressure, aromatherapy, transdermal nitroglycerin, TENS

• Dysmenorrhea
Limited data: low-fat vegetarian diet, pyridoxine, magnesium, vitamin-E, acupuncture,
acupressure, aromatherapy, transdermal nitroglycerin, TENS
Smoking cessation should be encouraged

• Dysmenorrhea
Secondary dysmenorrhea

• Dysmenorrhea
Starts later than teenage years or may present as a change in pattern, type, or intensity
of usual pain

• Dysmenorrhea
of usual pain
Pain usually starts just before the period and lasts throughout
Often associated with deep dyspareunia; can be associated with abnormal bleeding and
vaginal discharge

• Dysmenorrhea
of usual pain
vaginal discharge
Pathophysiology is similar i.e. release of PG, but an underlying cause must be present

• Dysmenorrhea
of usual pain
vaginal discharge
Pathophysiology is similar i.e. release of PG, but an underlying cause must be present
Causes include endometriosis/adenomyosis, chronic pelvic infection, IUCD/IUS,
endometrial polyps, cervical stenosis, submucosal fibroid, history of pelvic/abdominal
surgery, intrauterine adhesions, psychosexual problems

• Dysmenorrhea
Assessment includes abdominal examination, bimanual pelvic examination, vaginal
speculum examination
Do a cervical smear (if overdue). Offer STI screen (if sexually active)
Do a pelvic U/S (by referral)
Further investigations include laparoscopy, hysteroscopy (through referral)

• Dysmenorrhea
Assessment includes abdominal examination, bimanual pelvic examination, vaginal
speculum examination
Do a cervical smear (if overdue). Offer STI screen (if sexually active)
Do a pelvic U/S (by referral)
Further investigations include laparoscopy, hysteroscopy (through referral)
Treat the underlying cause

References
• OHGP
• Dr. Latha Chandran (Mullerian agenesis)
• Dr. Al-Hennawy (Asherman’s syndrome)
• Medscape.com
• Slidehsare.com

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