menstrual disorders
DESCRIPTION
Menstrual Disorders and their managementTRANSCRIPT
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Menstrual DisordersDr.Ahmed RashadPGY2 Family Medicine
Under Supervision of Dr.Leena Kadhem
+Objectives
To understand the physiology of the normal menstrual cycle
To know definition and types of abnormal uterine bleeding
How to approach a case of abnormal uterine bleeding
Amenorrhea; types and causes
Dysmenorrhea; types and management
When to refer to secondary care
+Introduction
Menstrual disorders and abnormal uterine bleeding (AUB) are among the most frequent gynecologic complaints. [1]
Menstrual disorders frequently affect the quality of life of adolescents and young adult women and can be indicators of serious underlying problems.
+Normal Menstrual Cycle
The normal menstrual cycle is a tightly coordinated cycle of stimulatory and inhibitory effects that results in the release of a single mature oocyte from a pool of hundreds of thousands of primordial oocytes.
+H-P-O axis
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The average adult menstrual cycle is 28 days, with a range of 24 to 35 days , and lasts four to six days.
The median blood loss during each menstrual period is 30 mL; the upper limit of normal is 80 mL.
+CASE 1
A 35-year-old female presents to your office with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses comes twice a month but other times will skip 2 months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse. She denies any vaginal discharge or any other symptoms. She is a nonsmoker. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of sexually transmitted infections (STIs). On physical examination, her blood pressure is 120/80 mmHg and her body mass index (BMI) is 32. Her physical examination is normal, including pelvic exam.
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The patient’s bleeding pattern is best described as …?
The most likely diagnosis is …?
What is the most likely underlying mechanism for
this patient’s abnormal bleeding?
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Abnormal Uterine Bleeding
+Definition
Abnormal uterine bleeding refers to uterine bleeding outside of the parameters noted below :
Duration greater than eight days
Flow greater than 80 mL/cycle or subjective impression of heavier-than-normal flow (ie, more than six full pads or tampons per day)
Occur more frequently than every 24 days or less frequently than every 38 days
Intermenstrual bleeding or postcoital spotting
Absence of menses
+ Oligomenorrhea: menstruation occurring with intervals of more
than 35 days
Polymenorrhea: menstruation occurring regularly with intervals of less than 21 days
Metrorrhagia: menstrual bleeding occurring at irregular intervals or bleeding between menstrual cycles
Menorrhagia: regular menstrual cycles with excessive flow (technically more than 80 mL of volume) or menstruation lasting more than 7 days
Menometrorrhagia: menstrual bleeding occurring at irregular intervals with excessive flow or duration
+Prevalence and Impact
In population-based studies, approximately 10 to 35 percent of women report having menorrhagia. [2-4]
Menorrhagia is a common reason for referral to a gynecologist .
Iron deficiency anemia develops in 21 to 67 percent of cases. [2]
Excessive and irregular bleeding can affect the quality of life. Absenteeism from work or school is bothersome to many women and bleeding may also interfere with sexual activity.
+Causes throughout Woman’s Lifetime
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Anovulatory Uterine Bleeding
+Pathophysiology Estrogen breakthrough bleeding
Anovulatory cycles have no corpus luteal formation. Progesterone is not produced. The endometrium continues to proliferate under the influence of unopposed estrogen.
Estrogen withdrawal bleeding
This frequently occurs in women approaching the end of reproductive life. Ovarian follicles in these women secrete less estradiol. Fluctuating estradiol levels might lead to insufficient endometrial proliferation with irregular menstrual shedding.
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+Causes
In Adolescents
Failure occurs secondary to delayed maturation of the hypothalamic-pituitary axis. Normal in 1-2 years after menarche.
Peri-menopausal
Anovulatory bleeding in menopausal transition is related to declining ovarian follicular function.
+ Approximately 6 to 10 percent of women with anovulation
have underlying polycystic ovary syndrome.
Uncontrolled diabetes mellitus, hypo- or hyperthyroidism, and hyperprolactinemia also may cause anovulation by interfering with the hypothalamic-pituitary-ovarian axis.
Antiepileptics (especially valproic acid [Depakene]) may cause weight gain, hyperandrogenism, and anovulation.
Use of typical antipsychotics (e.g., haloperidol), and some atypical antipsychotics (e.g. risperidone [Risperdal]) may contribute to anovulation by raising prolactin levels
+Evaluation
First, whom to evaluate ?
Patients with irregular cycles who should be evaluated include
a)adolescents with consistently more than three months between cycles or
b)those with irregular cycles for more than three years [3];
c)women who are likely perimenopausal and have increased volume or duration of bleeding over baseline.
+ Initial evaluation of anovulatory uterine bleeding should
include
a) Confirm a uterine source of bleeding on physical examination
b)Perform a pregnancy test.
c) Assess whether the woman is pre- or postmenopausal.
d)Evaluate the pattern, volume, and duration of blood loss.
+e) Assess ovulation:
• Ovulation can generally be documented clinically, based on regular cyclic menses with molimina (eg, breast tenderness, bloating or pelvic discomfort, mood changes, thin vaginal discharge), or
• can be confirmed by a serum progesterone level measured in the presumed luteal phase of the menstrual cycle; in most laboratories, a level of >4 ng/dL confirms ovulation.
f) Perform laboratory testing for anemia
g) Perform pelvic sonography to assess for uterine or other reproductive tract abnormalities that may contribute to uterine bleeding.
+g) ACOG recommends endometrial tissue assessment to
rule out cancer in
i. in adolescents and in women younger than 35 years with prolonged unopposed estrogen stimulation,
ii. women 35 years or older with suspected anovulatory bleeding, and
iii. women unresponsive to medical therapy
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Ovulatory Uterine Bleeding
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Ovulatory abnormal uterine bleeding, or menorrhagia, presents as bleeding that occurs at normal, regular intervals but that is excessive in volume or duration.
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Etiologies
+Bleeding disorders
Suspected if :
i.Menorrhagia since menarche
ii.Family history of bleeding disorders
iii.Personal history of 1 or more of the following:• Notable bruising without known injury• Bleeding of oral cavity or gastrointestinal tract without
obvious lesion• Epistaxis greater than 10 minutes duration (possibly
necessitating packing or cautery.
+CASE 2
A 27-year-old nulligravida female presents to your office for routine exam. Upon gynecological history, you discover that she has a 5-year history of oligomenorrhea, with only approximately two or three menses a year. She denies intercycle spotting or premenstrual symptoms. Her last menses was 3 months ago. Her blood pressure is 120/75 mmHg and her BMI is 34. Her physical exam reveals a moderate amount of facial hair and facial acne. Her pelvic examination is unremarkable
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What condition do you suspect in this patient?
What are the treatment options ?
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Amenorrhea
+Definition and types
Primary amenorrhea is defined as the absence of menses at:
i. age 16 in the presence of normal growth and secondary sexual characteristics, or
ii. age 14, if no menses have occurred and there is an absence of secondary sexual characteristics.
Secondary amenorrhea is the absence of menses for three months in women with previously normal menstruation and for nine months in women with previous oligomenorrhea.
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Primary Amenorrhea
+Etiology of 1ry AmenorrheaHypothalamic and Pituitary causes
①Functional hypothalamic amenorrhea.
•Abnormal hypothalamic gonadotropin-releasing hormone (GnRH) secretion decreased gonadotropin pulsations
i.absent LH surges
ii.absence of normal follicular development
iii.anovulation.
•Multiple factors may contribute to the pathogenesis of functional hypothalamic amenorrhea, including eating disorders (such as anorexia nervosa), exercise, and stress
+② Congenital GnRH deficiency or idiopathic
hypogonadotropic hypogonadism
Kallmann’s Syndrome ?
③ Constitutional delay of puberty
• characterized by both delayed adrenarche and gonadarche.
④ Hyperprolactinemia
+Ovarian Causes
①Gonadal dysgenesis
②Turner syndrome
③Polycystic ovary syndrome
④Premature ovarian failure
•Loss of ovarian function before age of 40
•Idiopathic, but maybe related to a variant gene.
+Polycystic Ovarian Syndrome
+Congenital disorders of the uterus and vagina
①Müllerian agenesis causes approximately 15 percent of primary amenorrhea.[4]
②Imperforate hymen
③Transverse vaginal septum
+Diagnosis
History
Detailed history of pubertal development
Family history of menarche, pubertal development
History of weight loss, stress, exercise (athletic activity)
Detailed dietary history
History of contraception, medications
History suggestive of CNS disease (eg, headaches, visual changes)
History of chronic illnesses (eg, Crohn disease)
+Physical examination
Height, weight, and growth charts
Breast development, pubic hair
Syndromic appearance (eg, short stature, webbed neck)
Visual fields, thorough neurologic examination, optic fundi
Evidence of hyperandrogenism (eg, acne, hirsutism, clitoromegaly)
Evidence of thyroid disease
Evidence of chronic illnesses
Evidence of pregnancy
+Evaluation
Primary amenorrhea is evaluated most efficiently by focusing on the
a)presence or absence of breast development (a marker of estrogen action and therefore function of the ovary),
b)the presence or absence of the uterus (as determined by ultrasound, or in more complex cases by magnetic resonance imaging)
c)and the follicle-stimulating hormone (FSH) level.
+Etiology of 2ry Amenorrhea PREGNANCY is the most common cause of
secondary amenorrhea.
Hypothalamic dysfunction
① Functional hypothalamic amenorrhea
② Inflammatory or infiltrative diseases (eg.Lymphoma)
③ Brain tumors (i.e. Craniopharyngioma)
④ Cranial irradiation
⑤ Pituitary stalk dissection or compression
+ Pituitary dysfunction
① Hyperprolactinemia • Prolactinomas account for 20% of secondary
amenorrhea• Account for 90% of secondary amenorrhea due to
pituitary problems
② Pituitary tumors• Acromegaly• Corticotroph adenomas (i.e. Cushing’s disease)• Meningioma (of the sella), germinoma, glioma
③ Empty sella syndrome
④ Pituitary infarct/pituitary apoplexy• Sheehan’s syndrome
+ Ovarian dysfunction
•Menopause: defined as 12 months of amenorrhea in a woman over age 45 in the absence of other biological or physiological causes.
•Premature ovarian failure
•Surgical removal
•Polycystic ovarian disease
+ Uterine causes
① Acquired scarring of the endometrium
• due to instrumentation e.g. Asherman’s Syndrome• due to infection eg. tuberculosis
① Cervical stenosis, often due to instrumentation
+Prolactin ≤ 100 ng per mL (100 mcg per L)Altered metabolismLiver failureRenal failureEctopic productionBronchogenic (e.g., carcinoma)Breastfeeding
Prolactin > 100 ng per mLEmpty sella syndromePituitary adenoma
+CASE 3
A 15-year-old nulligravida female presents with her
mother for evaluation of painful periods. Menarche was
at age 14. Her periods are typically every 4–8 weeks and
are very painful. She has missed 1–2 days of school with
each menses because of the severe pain and has been
suspended from the volleyball team because of missed
practices. She denies intercourse. She has never had a
pelvic examination. Her review of systems is otherwise
negative.
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What is the MOST likely etiology of her
irregular cycles?
What is the etiology?
What is the best first-line treatment for this
patient?
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Dysmenorrhea
+Definition and types
Dysmenorrhea is defined as difficult menstrual flow or painful menstruation. It is one of the most common gynecologic complaints in young women who present to clinicians.[5]
Dysmenorrhea can be divided into 2 broad categories: primary (spasmodic) and secondary (congestive).
+Primary dysmenorrhea
Primary dysmenorrhea is defined as menstrual pain that is not associated with macroscopic pelvic pathology.
It typically occurs in the first few years after menarche[6]and affects as many as 50% of postpubertal females.
In an epidemiologic study of an adolescent population (age range, 12-17 years), reported that dysmenorrhea had a prevalence of 59.7%. [7]
+Risk factors
Early age at menarche (< 12 years)
Nulliparity
Heavy or prolonged menstrual flow
Smoking
Positive family history
Obesity
+Pathophysiology
Current evidence suggests that the pathogenesis of primary dysmenorrhea is due to prostaglandin F2α (PGF2α), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium. [8]
+Treatment
Treatment is directed at providing relief from the cramping pelvic pain and associated symptoms .
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the best-established initial therapy for dysmenorrhea. [9] They decrease menstrual pain by lowering prostaglandin F2α (PGF2α) levels in menstrual fluid.
Oral Contraceptives also relieve symptoms, particularly if contraception is required.
+Secondary dysmenorrhea
Less common than primary dysmenorrhea
It is associated with pelvic pathology
It tends to occur several years after the menarche
The woman may complain of a change in the timing and intensity of her pain
The pain may last throughout menstruation
The pain may be associated with discomfort before the onset of menstruation.
+Causes
Leiomyomata (fibroids)
PID
Tubo-ovarian abscess
Endometriosis
+Management
Treatment of secondary dysmenorrhea involves correction of the underlying organic cause.
Specific measures (medical or surgical) may be required to treat pelvic pathologic conditions (eg, endometriosis) and to ameliorate the associated dysmenorrhea
+Resources [1] Caufriez A. Menstrual disorders in adolescence: pathophysiology and treatment. Horm Res 1991; 36:156.
[2]Côté I, Jacobs P, Cumming DC. Use of health services associated with increased menstrual loss in the United States. Am J Obstet Gynecol 2003; 188:343.
[3]Santer M, Warner P, Wyke S. A Scottish postal survey suggested that the prevailing clinical preoccupation with heavy periods does not reflect the epidemiology of reported symptoms and problems. J Clin Epidemiol 2005; 58:1206.
[4]Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract 2004; 54:359.
[3] Speroff L, Fritz MA. Amenorrhea. In: Clinical gynecologic endocrinology and infertility. 7th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins, 2005;401–64.
[4] ACOG Committee on Practice Bulletins—Gynecology. American College of Obstetricians and Gynecologists. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet. 2001;72(3):263–271.
[5] Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss--a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966; 45:320.
[6]Diaz A, Laufer MR, Breech LL; American Academy of Pediatrics Committee on Adolescence, American College of Obstetricians and Gynecologists Committee on Adolescent Health Care. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics. 2006;118(5):2245–2250.
[[7] Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics. Nov 1981;68(5):661-4
[8] Willman EA, Collins WP, Clayton SG. Studies in the involvement of prostaglandins in uterine symptomatology and pathology. Br J Obstet Gynaecol. May 1976;83(5):337-41
[8] Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol 2003; 17:75.
[9] Proctor M, Farquhar C. Dysmenorrhoea. Clin Evid. 2002;(7):1639–53.
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