menstrual disorders
DESCRIPTION
o&g update course 2012 hospital segamatTRANSCRIPT
Menstrual DisordersMenstrual Disorders
DR:HUSSEIN H AKLDR:HUSSEIN H AKLO&G SPECIALISTO&G SPECIALISTMOH MALAYSIAMOH MALAYSIA
18 nov.201218 nov.2012
Menstrual CycleMenstrual Cycle
DefinitionsDefinitions
Menorrhagia Menorrhagia Excessive (>80ml) uterine bleeding Excessive (>80ml) uterine bleeding Prolonged (>7days) regularProlonged (>7days) regular
DUB DUB Abnormal Bleeding, no obvious organic cause Abnormal Bleeding, no obvious organic cause usually anovulatoryusually anovulatory
Oligomenorrhea Oligomenorrhea Uterine bleeding occurring at Uterine bleeding occurring at intervals between 35 days and 6 monthsintervals between 35 days and 6 months
Amenorrhea Amenorrhea No menses x at least 6 monthsNo menses x at least 6 months
Metrorragia, Menometrorrhagia, Metrorragia, Menometrorrhagia, PolymenorrheaPolymenorrhea
Ovulatory vs Anovulatory cyclesOvulatory vs Anovulatory cycles
Anovulatory Anovulatory Oligo or Amenorrhea +/- MenorrhagiaOligo or Amenorrhea +/- Menorrhagia
Ovulatory Ovulatory Regular menstrual cycles (plus premenstrual symptoms such as Regular menstrual cycles (plus premenstrual symptoms such as
dysmenorrhea and mastalgiadysmenorrhea and mastalgia
DUBDUB
-Defn: Excessively heavy, prolonged or -Defn: Excessively heavy, prolonged or frequent bleeding of uterine origin that is frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic not due to pregnancy, pelvic or systemic diseasedisease
-Diagnosis of exclusion-Diagnosis of exclusion
- Anovulatory- Anovulatory
-Usually extremes of reproductive life and in -Usually extremes of reproductive life and in pts with PCOSpts with PCOS
DUB pathophysiologyDUB pathophysiology
Disturbance in the HPO axis thus changes Disturbance in the HPO axis thus changes in length of menstrual cyclein length of menstrual cycle
No progesterone withdrawal from an No progesterone withdrawal from an estrogen-primed endometriumestrogen-primed endometrium
Endometrium builds up with erratic Endometrium builds up with erratic bleeding as it breaks down.bleeding as it breaks down.
16year old with daily heavy vaginal 16year old with daily heavy vaginal bleeding with clots, no crampsbleeding with clots, no cramps
5ft 7in, 105ibs, normal 5ft 7in, 105ibs, normal sec. sex xristics, pelvic sec. sex xristics, pelvic normalnormal
Menarche 14, 2 periods Menarche 14, 2 periods last year, heavy lasts 2 last year, heavy lasts 2 weeks, virginal.weeks, virginal.
I month hx of daily heavy I month hx of daily heavy vag bleeding with clots, 8 vag bleeding with clots, 8 to 10 pads x dayto 10 pads x day
No associated symptomsNo associated symptoms
Picture of teenagerPicture of teenager
DUB managementDUB management
HCG, CBC, TSHHCG, CBC, TSH
? Coagulation workup? Coagulation workup
Ensure pap smear UTD if appropriateEnsure pap smear UTD if appropriate
>35 or Ca risk factors, tamoxifen use>35 or Ca risk factors, tamoxifen use
– – sample endometriumsample endometrium
DUB managementDUB management
I/V or I/M conjugated estrogen therapy I/V or I/M conjugated estrogen therapy acute DUB--How ?!!!. acute DUB--How ?!!!.
Usually followed by OCP or progestinUsually followed by OCP or progestin
Cyclic progestins for 10 to 12 days each Cyclic progestins for 10 to 12 days each cycle, consider mirena IUDcycle, consider mirena IUD
OCP OCP
D and C – old school, no longer D and C – old school, no longer recommended. recommended.
MenorrhagiaMenorrhagia
-Heavy vaginal bleeding that is not DUB-Heavy vaginal bleeding that is not DUB-Usually secondary to distortion of uterine -Usually secondary to distortion of uterine
cavity- heavy with or without prolongation cavity- heavy with or without prolongation (anatomic).(anatomic).
Uterus unable to contract down on open Uterus unable to contract down on open venous sinuses in the zona basalisvenous sinuses in the zona basalis
-Other causes organic, endocrinologic, -Other causes organic, endocrinologic, hemostatic and iatrogenichemostatic and iatrogenic
-Usually ovulatory-Usually ovulatory
40 year old with menorrhagia x 12 40 year old with menorrhagia x 12 monthsmonths
5ft’5”, 155Ibs, husband 5ft’5”, 155Ibs, husband ‘castrated’‘castrated’Had normal 28 day cycles Had normal 28 day cycles lasting 5 dayslasting 5 daysLast 1 year or so very Last 1 year or so very heavy periods with clots heavy periods with clots and occ. ‘flooding’ in the and occ. ‘flooding’ in the first 3 days with need to first 3 days with need to use >8pads/day fully use >8pads/day fully soaked, spots for up to 1 soaked, spots for up to 1 week after this.week after this.Dysmenorrhea, severe, Dysmenorrhea, severe, aching pain lower legsaching pain lower legsNormal recent papNormal recent pap
Picture of middle Picture of middle aged womanaged woman
Menorrhagia, Menorrhagia, ManagementManagement
HistoryHistory
Physical exam-Physical exam-anemia, obesity, androgen excess anemia, obesity, androgen excess e.g. hirsuitism, acne, ecchymosis/purpura, thyroid, e.g. hirsuitism, acne, ecchymosis/purpura, thyroid, galactorrhea, liver/spleen, Pelvic- Uterine, cervical and galactorrhea, liver/spleen, Pelvic- Uterine, cervical and adnexaladnexal
Menorrhagia, Menorrhagia, managementmanagement
HCG, CBC, TSHHCG, CBC, TSH
? Coagulation workup? Coagulation workup
Ensure pap smear UTD if appropriateEnsure pap smear UTD if appropriate
>35 or Ca risk factors, tamoxifen use>35 or Ca risk factors, tamoxifen use
sample endometriumsample endometrium
Other tests as INDICATED by HX and PEOther tests as INDICATED by HX and PE
Endometrial evaluation of Endometrial evaluation of menorrhagiamenorrhagia
Endometrial Endometrial BiopsyBiopsy
Sensitivity -91%Sensitivity -91%
False positive rate -False positive rate -2%2%
Office procedure, well tolerated, Office procedure, well tolerated, anesthesia and cervical dilation usually not anesthesia and cervical dilation usually not requiredrequired
Transvaginal Transvaginal Ultrasound Ultrasound (TVS)(TVS)
Sensitivity -88%Sensitivity -88% Good visualization of fibroids; may fail to Good visualization of fibroids; may fail to identify other intracavitary abnormalitiesidentify other intracavitary abnormalities
like polypslike polyps
Saline Infusion Saline Infusion Sonohysterosc-Sonohysterosc-
Opy (SIS)Opy (SIS)
Sensitvity -97%Sensitvity -97%
NPV -94%NPV -94%
Procedure of choice (detection and cost).Procedure of choice (detection and cost).
Sterile isotonic fluid is instilled into the Sterile isotonic fluid is instilled into the uterus under continuous visualization of uterus under continuous visualization of
endometrium with TVSendometrium with TVS
HysteroscopyHysteroscopy Sensitivity -100%Sensitivity -100% Highest cost. Better in pre-menopausal Highest cost. Better in pre-menopausal women. Does not reduce hysterectomy women. Does not reduce hysterectomy rate even without intracavitary path. Used rate even without intracavitary path. Used as gold standard for other proceduresas gold standard for other procedures
Menorrhagia, Menorrhagia, medical managementmedical management
NSAID’s, NSAID’s, 11stst line, 5 days, decrease prostaglandins line, 5 days, decrease prostaglandins
Danazol, Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks, Androgen and prog. competitor , amenorrhea in 4-6 weeks, androgenic side effectsandrogenic side effects
OCP’s, OCP’s, esp. if contraception desired, up to 60% dec. supp. HP axisesp. if contraception desired, up to 60% dec. supp. HP axis
Continous OCP’sContinous OCP’sOral continous progestins (day 5 to 26), Oral continous progestins (day 5 to 26), most most prescribed, antiestrogen, downregulates endormetriumprescribed, antiestrogen, downregulates endormetrium
Levonorgestrel IUD (Mirena), Levonorgestrel IUD (Mirena), High satisfaction rate that High satisfaction rate that approaches surgical techniquesapproaches surgical techniques
GnRH agonists, GnRH agonists, Inhibit FSH and LH release– hypogonadism, boneInhibit FSH and LH release– hypogonadism, bone
Conjugated estrogens for acute bleedingConjugated estrogens for acute bleedingOther treatments as indicated e.g. DDAVP for coagulation defectsOther treatments as indicated e.g. DDAVP for coagulation defects
Menorrhagia, Menorrhagia, surgical managementsurgical management
UAE
? D & CHysterect-
omy
Myomectomy
Ablation
Surgical
Menorrhagia, Menorrhagia, Surgical ManagementSurgical Management
Ablation
2nd Generation1st Generation
Resection (TCRE)
Cryoablation Rollerball RadiofrequencyThermalBaloon
Microwave
Menorrhagia, Menorrhagia, management summarymanagement summary
Tailor treatment to individual patient.Tailor treatment to individual patient.
Consider patients age, coexisting medical Consider patients age, coexisting medical diseases, FH, desire for fertility, cost of rx diseases, FH, desire for fertility, cost of rx and adverse effectsand adverse effects
Surgical management reserved for organic Surgical management reserved for organic causes (e.g fibroids) or when medical causes (e.g fibroids) or when medical management fails to alleviate symptomsmanagement fails to alleviate symptoms
Amenorrhea, Amenorrhea, physiologic causesphysiologic causes
Lactational Lactational
Prepubertal femalePrepubertal female
Pregnant femalePregnant female
Postmenopausal femalePostmenopausal female
Primary AmenorrheaPrimary Amenorrhea
Absence of menses by age 14 with Absence of menses by age 14 with absence of SSC (e.g. breast development) absence of SSC (e.g. breast development) or absence by age 16 with normal SSCor absence by age 16 with normal SSC
Only 3 conditions unique to primary, other Only 3 conditions unique to primary, other causes of amenorrhea can cause eithercauses of amenorrhea can cause either
-Vaginal agenesis-Vaginal agenesis
-Androgen insensitivity syndrome-Androgen insensitivity syndrome
-Turners syndrome (45, X0)-Turners syndrome (45, X0)
Amenorrhea, Amenorrhea, causescauses
Generalized pubertal delay e.g. Turner Generalized pubertal delay e.g. Turner syndromesyndrome
Normal puberty e.g. PCOSNormal puberty e.g. PCOS
Abnormalities of the genital tract e.g. Abnormalities of the genital tract e.g. Ashermans syndromeAshermans syndrome
Amenorrhea, Amenorrhea, managementmanagement
Hx. Hx. PE- These are probably the most important PE- These are probably the most important aspects in diagnosisaspects in diagnosisRemember to always rule out pregnancyRemember to always rule out pregnancyH & P suggestsH & P suggests
- Ovarian-axis problem- TSH, prolactin, FSH, LHOvarian-axis problem- TSH, prolactin, FSH, LH- Hirsuitism-Testosterone, DHEAS, Hirsuitism-Testosterone, DHEAS,
androstenedione and 17-OH progesteroneandrostenedione and 17-OH progesterone- Chronic ds.- ESR, LFT’s, BUN, cr and UAChronic ds.- ESR, LFT’s, BUN, cr and UA- CNS- MRICNS- MRI
Amenorrhea, Amenorrhea, managementmanagement
If H and P gives no clues to diagnosis-If H and P gives no clues to diagnosis-excitingexciting
Use step wise approach to diagnosisUse step wise approach to diagnosis
Evaluation of Secondary Amenorrhea
TABLE 4Causes of Amenorrhea
Hyperprolactinemia Prolactin ≤ 100 ng per mL (100 mcg per L) Altered metabolism
Liver failure Renal failure
Ectopic production Bronchogenic (e.g., carcinoma) Gonadoblastoma Hypopharynx Ovarian dermoid cyst Renal cell carcinoma Teratoma
Breastfeeding Breast stimulation Hypothyroidism Medications
Oral contraceptive pills Antipsychotics Antidepressants Antihypertensives
Histamine H2
receptor blockers Opiates, cocaine
Prolactin > 100 ng per mL Empty sella syndrome Pituitary adenoma
Hypergonadotropic hypogonadism Gonadal dysgenesis
Turner's syndrome* Other*
Postmenopausal ovarian failure Premature ovarian failure
Autoimmune Chemotherapy Galactosemia Genetic 17-hydroxylase deficiency syndrome Idiopathic Mumps Pelvic radiation
Hypogonadotropic hypogonadism Anorexia or bulimia nervosa Central nervous system tumor Constitutional delay of growth and puberty* Chronic illness
Chronic liver disease Chronic renal insufficiency Diabetes Immunodeficiency Inflammatory bowel disease Thyroid disease Severe depression or psychosocial stressors
Cranial radiation
Hypogonadotropic hypogonadism (continued) Excessive exercise Excessive weight loss or malnutrition Hypothalamic or pituitary destruction Kallmann syndrome* Sheehan's syndrome Normogonadotropic Congenital
Androgen insensitivity syndrome* Müllerian agenesis*
Hyperandrogenic anovulation Acromegaly Androgen-secreting tumor (ovarian or adrenal) Cushing's disease Exogenous androgens Nonclassic congenital adrenal hyperplasia Polycystic ovary syndrome Thyroid disease
Outflow tract obstruction Asherman's syndrome Cervical stenosis Imperforate hymen* Transverse vaginal septum*
Other Pregnancy Thyroid disease
*-Causes of primary amenorrhea only.Information from references 3, 6, and 15.
Abnormal MenstruationAbnormal MenstruationHere’s what you need to remember!!Here’s what you need to remember!!
Always R/O pregnancy, check papAlways R/O pregnancy, check papTry to differentiate anovulatory from ovulatory bleedingTry to differentiate anovulatory from ovulatory bleedingGood history and physical is key( this applies to Good history and physical is key( this applies to amenorrhea as well)amenorrhea as well)Do a focused work up based on your H & P rather than a Do a focused work up based on your H & P rather than a random set of studiesrandom set of studiesIn amenorrhea, where no indication of cause based on In amenorrhea, where no indication of cause based on
H & P, follow the stepwise algorithm for diagnosisH & P, follow the stepwise algorithm for diagnosisKnow the INDICATIONS for endometrial samplingKnow the INDICATIONS for endometrial sampling
Thank You
Thank You
Egypt
ReferencesReferences
Slides 25 and 26 courtesy of:Slides 25 and 26 courtesy of:
Master-Hunter T, Heiman D, Amenorrhea: Master-Hunter T, Heiman D, Amenorrhea: Evaluation and Treatment. AFP April 15Evaluation and Treatment. AFP April 15thth 2006.2006.