menstrual function/dysfunctions disorders- anitha mullangi final.pdfmenorrhagia (heavy menstrual...

Menstrual Function/Dysfunctions

Anitha Mullangi, MD, MHCM, CPE, FAAFP

Chief Medical Officer,

St. Johns WellChild and Family Center

Board of Directors, NRIVA

www.nriva.org 1

www.nriva.org

Disclaimer

This is an information session onlyPlease talk to your doctor for all diagnosis and treatment options

2

www.nriva.org

Questions?

Your phones are muted.

Please wait for the phones to be unmuted.

If you joined via webinar- you can ask questions via webinar

3

www.nriva.org

Phases of Menstrual Cycle

4

www.nriva.org

Menstruation The average age for the onset of menstruation 12.4

years old.

The usual average range of age of onset is 9-17 years

old.

The average interval in between cycles is 28 days.

Cycles that range from 21-35 days is also normal.

The average duration of menstrual flow is 2-7 days.

The average amount of menstrual flow is 30-80 mL.

The normal color of menstrual flow is dark red, which is

a combination of blood, mucus, and endometrial cells.

5

www.nriva.org

Stages of Menstrual Cycles

6

www.nriva.org

Menarche

• Physical changes that occur during puberty in girls

• First sign- Development of breasts- Between the ages of 8-13 yrs

• Appearance of hair in the armpit.

• Widening of hips and appearance of pubic hair. ...

• Growth spurt. ...

• Onset of menstruation.

• It is the first period in a girl’s life begins about 2 to 2½ years after her first signs of puberty (sometimes pubic hair comes first)

• Usually occurs at around 12 years of age

7

www.nriva.org

PMSPremenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

• Affect up to 12% of women, can occur anytime between menarche and menopause

• Not associated with age, educational achievement, or employment status

• Cyclical nature of symptoms- Angry outbursts, anxiety, confusion, depression, irritability, abdominal bloating, breast pain/swelling, headaches, weight gain

• Symptoms that cause significant impairment starting after the ovulation (luteal phase) but resolve shortly after the periods

• Treatment• Select serotonergic antidepressants are first-line treatments

• Cognitive behavior therapy

• Oral contraceptives

• Calcium supplementation

• Quetiapine (Seroquel) 8

www.nriva.org

Amenorrhea

• Primary amenorrhea - failure to reach menarche. • if there is no pubertal development by 13 years of age,

• if menarche has not occurred five years after initial breast development, or

• if the patient is 15 years or older.

• Secondary amenorrhea- cessation of menses in the absence of pregnancy, lactation, cycle suppression with pills or menopause.• previously regular menses for three months or

• previously irregular menses for six months

9

www.nriva.org

Questions?

Your phones are muted.

If you joined via webinar- ask the question via webinar

10

www.nriva.org

Abnormal Uterine Bleeding (AUB)

• Effects 14–25% of women of reproductive age• It can impact a woman’s daily activity, health, quality of life• Can impact a woman’s social and sexual life.

Abnormal uterine bleeding:

• Bleeding or spotting between periods

• Bleeding or spotting after sex

• Heavy bleeding during your period

• Menstrual cycles that are longer than 38 days or shorter than 24 days

• “Irregular” periods in which cycle length varies by more than 7–9 days

• Bleeding after menopause

11

www.nriva.org

Definitions

Polymenorrhoea- frequency less than 24 days, but regular intervals

Menorrhagia (Heavy Menstrual Bleeding)- heavy or prolonged period at regular intervals

Metrorrhagia- periods at irregular intervals

Menometrorrhagia- a combination of Menorrhagia and Metrorrhagia

- heavy or prolonged period at irregular intervals

Hypomenorrhoea- scanty or very light periods

Oligomenorrhea- infrequent menstrual periods beyond 35 days

Intermentstrual Bleeding- occasional bleeding in between regular periods

12

www.nriva.org

Causes

Causes in the UterusPregnancyPolypAdenomyosis EndometriosisLeiomyoma Endometrial hyperplasiaInfectionsCancer in the uterus, cervix

Causes in the OvaryAnovulationPCOSOvarian CystsOvarian cancer/tumor

Endocrine disordersThyroid diseasesUncontrolled DiabetesHyperprolactinemiaEating disordersExcessive sports

Bleeding disordersCoagulopathyPlatelet disordersVon Willebrand disease Anemia

Other causesMedicationsPerimenopauseContraceptive methods

13

www.nriva.org

Causes in the Uterus

PregnancyAdenomyosis EndometriosisFibroid PolypEndometrial hyperplasiaInfectionsCancer in the uterus, cervix

14

Signs and symptoms

• AUB, usually in 40s to 50s

• Painful, cramping and/or heavy periods

• Enlarged uterus

Diagnosis

• Transvaginal Ultrasound

• MRI

Treatment

• Nonsteroidal Anti-inflammatory drugs

• Hormonal therapy

• Uterine artery embolization

• Endometrial ablation

• Hysterectomy

• Menopause

Adenomyosis“The tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus”

www.nriva.org 15

Endometriosis

www.nriva.org

The endometrium grows outside your uterus. Endometriosis most commonly involves ovaries, fallopian tubes and the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond pelvic organs.

Signs and Symptoms:

• Seen in-10 percent of women.

• Pelvic pain. Painful periods and pain with intercourse

• Pain with bowel movements or urination- especially during periods.

• Excessive bleeding- heavy periods or bleeding between periods

• Infertility-40% of women

• Other symptoms- fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

16

Endometriosis- Risk Factors

www.nriva.org

• Never giving birth (Nulliparous)

• Increases with increased exposure to endometrial material-

• Short menstrual cycles or longer bleeding days

• Starting your period at an early age

• Menopause at an older age

• Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen

• Low body mass index

• Family history of endometriosis

• Uterine abnormalities

17

Endometriosis- Management

www.nriva.org

Medical management

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Hormonal medications

• birth control pills

• Depo Provera injections/ tablets

• Gonadotropin-releasing hormone agonists

• Hormonal IUDs- Mirena

Surgical Treatment• Surgery to remove the

nerves causing the pain• Surgical ablation• Removal of Uterus and

Ovaries

Diagnosis

• Pelvic exam

• Laparoscopy- direct visualization of lesions with histologic confirmation

• MRI

18

Leiomyoma - FibroidsSigns and symptoms• most common benign tumors in women of reproductive age

• Up to 80% of women by 50 years of age

• Painful, cramping and/or heavy periods

• Pelvic pressure/heaviness, low back pain

• Urinary frequency, urgency, retention

• Constipation

• Pain with intercourse

• Enlarged uterus/ abdominal enlargement

• preterm labor, obstruction of labor, Pregnancy loss, Infertility

Increased Risk• Family history

• Increase in age, African descent

• Early menarche (before 10yrs)

• Never been pregnant

• Obesity

Decreased risk • Increased pregnancies • Late menarche (older than 16 yrs)• Smoking• Use of oral contraceptives

www.nriva.org 19

Fibroids

Annual direct treatment costs $4.1–9.4 billion,

Indirect costs-lost work hours $1.55–17.2 billion

Classification

Uterine fibroids are classified based on location

on the uterus

Diagnosis

• Transvaginal Ultrasound

• Sonohysterography/ Hysteroscopy

www.nriva.org 20

Fibroids- TreatmentTreatment should satisfy four goals

• relief of signs and symptoms

• sustained reduction of the size of fibroids

• maintenance of fertility

• avoidance of harm

Medical Treatment

• Nonsteroidal Anti-inflammatory drugs

• Tranexamic acid

• Gonadotropin-releasing hormone agonists , e.g. Lupron

• Oral Contraceptives

• Levonorgestrel-releasing intrauterine system (Mirena)

• Selective progesterone receptor (SPRMs)

www.nriva.org 21

Fibroids- surgerySurgical Treatment

The symptoms and treatment options are affected by the size, number, and location of the tumors

• Uterine artery embolization

• Magnetic resonance guided focused ultrasound surgery

• Myomectomy

• Hysterectomy

www.nriva.org 22

Diagnosis

• Transvaginal Ultrasound

• Hysteroscopy/ Sonohysterography

Treatment

• Watchful waiting

• Surgical removal-• Endometrial polypectomy/ ablation

Endometrial Polyps

www.nriva.org

www.nriva.org

Cervical cancer screening

Age Screening needed

Below 21 years No test needed

21-29 years Pap Smear every 3 years

HPV testing is not recommended

30-65 years Pap Smear every 3 years

Pap Smear and an HPV test (co-testing) every 5 years

Over 65 years Stop cervical cancer screening if:• no history of moderate or severe abnormal cervical cells or cervical cancer,

and• three negative Pap test results in a row or • two negative co-test results in a row within the past 10 years, with the most

recent test performed within the past 5 years.• Hysterectomy with cervix removed for a non- cancer

24

www.nriva.org

Questions?

Your phones are muted.

If you joined via webinar- ask the question via webinar

25

www.nriva.org

• Anovulation

• PCOS

• Ovarian Cysts

• Ovarian cancer/tumor

Causes in the Ovary

26

www.nriva.org

PCOS

Symptoms of PCOS

•Abnormal Menstrual patterns

•Oligomenorrhea (> 35days but < 6 months)

•Amenorrhea (> 6 months after cycles establsied)

•Hirsutism- increase hair in male distribution pattern

•Infertility

•Obesity and metabolic syndrome- 50%

•Sleep Apnea

Polycystic ovaries

2003-Rotterdam criteria for diagnosis

PCOS is the most common endocrine disorder among women between the ages of 18 and 44

27

www.nriva.org

Signs of PCOS

28

www.nriva.org

PCOS Labs

29

www.nriva.org

• Life style modifications- Diet and exercise

• Hormonal Contraceptives- Estradiol/Cyproterane Acetate

• Ovulation Induction- Clomiphene

• Hirsutism- Spironolactone, Eflornithine (Vaniqa), Finasteride, Flutamide

• Metformin, Letrozole

• Bilateral Ovarian drilling

PCOS Management

30

www.nriva.org 31

Endocrine disorders

• Thyroid diseases

• Uncontrolled Diabetes

• Hyperprolactinemia

• Eating disorders

• Excessive sports

www.nriva.org 32

Thyroid disease

www.nriva.org

• No periods or decreased periods or increased periods• Anovulation or no egg formation (Infertility)• Hypertension• Hypothyroidism (does not make enough thyroid hormones)

• Weight gain, dry skin, thinning of hair, constipation, increased sleep,

• Feeling cold, tired, down, slow heart rate, hoarse voice• Thyroid hormone decreases• TSH increases• Prolactin may increase

• Hyperthyroidism• Weight loss, palpitations, trouble sleeping, increased sweating• Feeling anxious, hungry, weakness• Thyroid hormone increases• TSH decreases• Can cause Osteoporosis

33

www.nriva.org

Questions?

Your phones are muted.

If you joined via webinar- ask the questions via webinar

34

www.nriva.org

• Bleeding Disorders• Medications

• Seizure medications• Antipsychotics

• Perimenopause• Contraceptive agents

• OC pills• IUD• Nexplanon

Other causes

35

www.nriva.org

Bleeding Disorders

Bleeding disordersCoagulopathyPlatelet disordersVon Willebrand disease Anemia

Test for bleeding disorder in adolescents and in

women with one or more of the following risk factors:

• family history of bleeding disorder

• menses lasting seven days or more with flooding

or impairment of activities with most periods

• history of treatment for anemia

• history of excessive bleeding with tooth extraction,

delivery or miscarriage, or surgery

36

No menstrual periods for 12 consecutive months and

No other biological or physiological cause can be identified.

Average age of onset: 51 years

www.nriva.org

Menopause

37

www.nriva.org

• Irregular Periods

• Physical changes

Weight gain, wrinkles, hair growth on lips, chin, chest

• Emotional symptoms

Mood disturbances, irritability, sleeplessness

• Urogenital atrophy

Vaginal dryness, dyspareunia, vulvar itching, frequent urination, urgency, and recurrent urinary infections

• Incidence 10-40% of menopausal women

• Vasomotor Symptoms

Hot flushes, extreme heat in the upper body (face), sweating, flushing, chills, clamminess, anxiety, palpitations

• 87% women report daily; 33% report > 10 flushes per day

• Symptom lasts 6 mos- 2 years

Symptoms of Menopause

38

www.nriva.org

Women with a uterus

• Hot flashes are the most common indication for hormone therapy.

• Cyclic therapy: • Estrogen : conjugated, micronized, transdermal (Vivel Dot)• Medroxyprogesterone Acetate (Provera) • Estrogen is taken every day, and progestin is added for several days

each month or for several days every 3 months or 4 months.

• Continuous therapy: • Estrogen and progestin are taken every day• Combined E2/Progestin (Prempro/Premphase)

• Estrogen + SERM: DUAVEE

• Side Effects: breast cancer, increased risk of heart disease, stroke, blood clots

• Advantages: Reduced hip fractures

HRT Formulations

39

www.nriva.org 40

www.nriva.org

Hormone Replacement Therapy

41

www.nriva.org

Natural remedies for Menopausal symptoms

Black cohosh: Black cohosh is used to help treat menopausal symptoms, such as hot flashes.

Red clover: has phytoestrogens which are similar to estrogen.

Soy: Soybeans make isoflavones, a type of phytoestrogen.

Relaxation and stress-reduction techniques: Yoga, tai chi, and acupuncture may help reduce

menopause symptoms, including sleep and mood problems, stress, and muscle and joint pain.

Hypnosis: helped decrease hot flashes by 74%

Kegel exercises: to strengthen pelvic floor muscles and reduce incontinence episodes.

Vaginal lubricants and moisturizers: Only water-soluble products should be used, eg:

Ospemifene (Osphena)

42

www.nriva.org

Foods for Menopausal Symptoms• Water• Calcium- milk and nonfat yogurt, and calcium supplements, broccoli, and legumes• vitamin D supplements• Whole grains. Some whole grains, such as steel-cut oatmeal, quinoa, barley, and brown rice• Iron-lean cuts of beef, eggs, iron-rich cereals, and grain• Soy- edamame, tofu, and other soy foods• Flaxseed- fiber, estrogen like compounds• Almonds- magnesium, vitamin E complex, and riboflavin• Cooked dried beans and peas, such as black beans, kidney beans, lentils, split peas, and garbanzos• Iodine- cod, dried prunes, canned tuna, cranberries, green beans, and navy beans.• Fiber- whole-grain breads, cereals, pasta, rice, fresh fruits, and vegetables• Omega 3 fatty acids

What to avoid• Alcohol, sugar, caffeine, and spicy foods, which can trigger hot flashes• High fat foods

43

www.nriva.org 44

Period Management

• Use more absorbent pads/tampons during heavy flow• Can use less absorbent pads/tampons during lighter flow• Change pads every 3-6 hours; tampons every 2-4 hours• Risks of wearing a single pad/tampon too long:

• Vaginal yeast infection (fungal infection)• Other bacterial infections• Rash or skin irritation• Bacterial odor from the blood• Toxic Shock Syndrome (TSS) with superabsorbent tampons

• Normal to pass blood, tissue, and blood clots during menstruation• Normal for periods to become irregular and lighter as you near menopause • If your flow is too light or too heavy, consult your gynecologist to rule out

other problems.

45

www.nriva.org 46

www.nriva.org

Questions?

Your phones are muted.

If you joined on phone- please press *6 to unmute to ask a question

If you joined via webinar- you can ask questions via webinar

47