menstrual disorders[1]

7/31/2019 Menstrual Disorders[1]

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Menstrual DisordersMenstrual Disorders

Oguchi A. Nwosu M.D.Oguchi A. Nwosu M.D.

Assistant ProfressorAssistant Profressor

Emory Family Medicine Dept.Emory Family Medicine Dept.

6/28/076/28/07


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Menstrual CycleMenstrual Cycle


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DefinitionsDefinitions

MenorrhagiaMenorrhagia Excessive (>80ml) uterine bleedingExcessive (>80ml) uterine bleedingProlonged (>7days) regularProlonged (>7days) regular

DUBDUB Abnormal Bleeding, no obvious organic causeAbnormal Bleeding, no obvious organic causeusually anovulatoryusually anovulatory

OligomenorrheaOligomenorrhea Uterine bleeding occurring atUterine bleeding occurring atintervals between 35 days and 6 monthsintervals between 35 days and 6 months

AmenorrheaAmenorrhea No menses x at least 6 monthsNo menses x at least 6 monthsMetrorragia, Menometrorrhagia,Metrorragia, Menometrorrhagia,

PolymenorrheaPolymenorrhea


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Ovulatory vs Anovulatory cyclesOvulatory vs Anovulatory cycles

AnovulatoryAnovulatoryOligo or Amenorrhea +/- MenorrhagiaOligo or Amenorrhea +/- Menorrhagia

OvulatoryOvulatoryRegular menstrual cycles (plus premenstrual symptoms such asRegular menstrual cycles (plus premenstrual symptoms such as

dysmenorrhea and mastalgiadysmenorrhea and mastalgia


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DUBDUB

-Defn: Excessively heavy, prolonged or-Defn: Excessively heavy, prolonged or

frequent bleeding of uterine origin that isfrequent bleeding of uterine origin that is

not due to pregnancy, pelvic or systemicnot 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


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DUB pathophysiologyDUB pathophysiology

Disturbance in the HPO axis thus changesDisturbance in the HPO axis thus changes

in length of menstrual cyclein length of menstrual cycle

No progesterone withdrawal from anNo progesterone withdrawal from an

estrogen-primed endometriumestrogen-primed endometrium

Endometrium builds up with erraticEndometrium builds up with erratic

bleeding as it breaks down.bleeding as it breaks down.


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16year old with daily heavy vaginal16year old with daily heavy vaginal

bleeding with clots, no crampsbleeding with clots, no cramps

5ft 7in, 105ibs, normal5ft 7in, 105ibs, normal

sec. sex xristics, pelvicsec. sex xristics, pelvic

normalnormal

Menarche 14, 2 periodsMenarche 14, 2 periods

last year, heavy lasts 2last year, heavy lasts 2

weeks, virginal.weeks, virginal.

I month hx of daily heavyI month hx of daily heavy

vag bleeding with clots, 8vag bleeding with clots, 8

to 10 pads x dayto 10 pads x day

No associated symptomsNo associated symptoms

Picture of teenagerPicture of teenager


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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


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DUB managementDUB management

I/V or I/M conjugated estrogen therapyI/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 eachCyclic progestins for 10 to 12 days each

cycle, consider mirena IUDcycle, consider mirena IUD

OCPOCPD and C old school, no longerD and C old school, no longer

recommended.recommended.


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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 uterinecavity- heavy with or without prolongationcavity- heavy with or without prolongation

(anatomic).(anatomic).Uterus unable to contract down on openUterus 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


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40 year old with menorrhagia x 1240 year old with menorrhagia x 12

monthsmonths5ft5, 155Ibs, husband5ft5, 155Ibs, husbandcastratedcastrated

Had normal 28 day cyclesHad normal 28 day cycleslasting 5 dayslasting 5 days

Last 1 year or so veryLast 1 year or so veryheavy periods with clotsheavy periods with clotsand occ. flooding in theand occ. flooding in thefirst 3 days with need tofirst 3 days with need touse >8pads/day fullyuse >8pads/day fullysoaked, spots for up to 1soaked, spots for up to 1

week after this.week after this.Dysmenorrhea, severe,Dysmenorrhea, severe,aching pain lower legsaching pain lower legs

Normal recent papNormal recent pap

Picture of middlePicture of middle

aged womanaged woman


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Menorrhagia,Menorrhagia, ManagementManagement

HistoryHistory

Physical exam-Physical exam-anemia, obesity, androgen excessanemia, obesity, androgen excesse.g. hirsuitism, acne, ecchymosis/purpura, thyroid,e.g. hirsuitism, acne, ecchymosis/purpura, thyroid,

galactorrhea, liver/spleen, Pelvic- Uterine, cervical andgalactorrhea, liver/spleen, Pelvic- Uterine, cervical andadnexaladnexal


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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


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Endometrial evaluation ofEndometrial evaluation of

menorrhagiamenorrhagiaEndometrialEndometrialBiopsyBiopsy

Sensitivity -91%Sensitivity -91%

False positive rate -2%False positive rate -2%

Office procedure, well tolerated, anesthesiaOffice procedure, well tolerated, anesthesiaand cervical dilation usually not requiredand cervical dilation usually not required

TransvaginalTransvaginal

Ultrasound (TVS)Ultrasound (TVS)

Sensitivity -88%Sensitivity -88% Good visualization of fibroids; may fail toGood visualization of fibroids; may fail toidentify other intracavitary abnormalitiesidentify other intracavitary abnormalities

like polypslike polyps

Saline InfusionSaline InfusionSonohysterosc-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 uterusSterile isotonic fluid is instilled into the uterusunder continuous visualization ofunder continuous visualization of

endometrium with TVSendometrium with TVS

HysteroscopyHysteroscopy Sensitivity -100%Sensitivity -100% Highest cost. Better in pre-menopausalHighest cost. Better in pre-menopausalwomen. Does not reduce hysterectomy ratewomen. Does not reduce hysterectomy rateeven without intracavitary path. Used aseven without intracavitary path. Used asgold standard for other proceduresgold standard for other procedures


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Menorrhagia,Menorrhagia, medical managementmedical management

NSAIDs,NSAIDs, 11stst line, 5 days, decrease prostaglandinsline, 5 days, decrease prostaglandinsDanazol,Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks,Androgen and prog. competitor , amenorrhea in 4-6 weeks,androgenic side effectsandrogenic side effects

OCPs,OCPs, esp. if contraception desired, up to 60% dec. supp. HP axisesp. if contraception desired, up to 60% dec. supp. HP axis

Continous OCPsContinous OCPsOral continous progestins (day 5 to 26),Oral continous progestins (day 5 to 26), mostmostprescribed, antiestrogen, downregulates endormetriumprescribed, antiestrogen, downregulates endormetrium

Levonorgestrel IUD (Mirena),Levonorgestrel IUD (Mirena), High satisfaction rate thatHigh satisfaction rate thatapproaches 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


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Menorrhagia,Menorrhagia, surgical managementsurgical management

UAE

? D & CHysterect-

omy

Myomectomy

Ablation

Surgical


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Menorrhagia,Menorrhagia, Surgical ManagementSurgical Management

Ablation

2nd Generation1st Generation

Resection (TCRE)

Cryoablation Rollerball RadiofrequencyThermal

BaloonMicrowave


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Menorrhagia,Menorrhagia, management summarymanagement summary

Tailor treatment to individual patient.Tailor treatment to individual patient.

Consider patients age, coexisting medicalConsider patients age, coexisting medical

diseases, FH, desire for fertility, cost of rxdiseases, FH, desire for fertility, cost of rx

and adverse effectsand adverse effects

Surgical management reserved for organicSurgical management reserved for organic

causes (e.g fibroids) or when medicalcauses (e.g fibroids) or when medical

management fails to alleviate symptomsmanagement fails to alleviate symptoms


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Amenorrhea,Amenorrhea, physiologic causesphysiologic causes

Male genderMale gender

Prepubertal femalePrepubertal female

Pregnant femalePregnant femalePostmenopausal femalePostmenopausal female


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Primary AmenorrheaPrimary Amenorrhea

Absence of menses by age 14 withAbsence 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, otherOnly 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)


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Amenorrhea,Amenorrhea, causescauses

Generalized pubertal delay e.g. TurnerGeneralized 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


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Amenorrhea,Amenorrhea, managementmanagement

Hx.Hx.

PE- These are probably the most importantPE- These are probably the most importantaspects in diagnosisaspects in diagnosis

Remember to always rule out pregnancyRemember to always rule out pregnancy

H & 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, LFTs, BUN, cr and UAChronic ds.- ESR, LFTs, BUN, cr and UA- CNS- MRICNS- MRI


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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


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Evaluation of Secondary Amenorrhea


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TABLE 4Causes of Amenorrhea

HyperprolactinemiaProlactin 100 ng per mL (100mcg per L)

Altered metabolismLiver failureRenal failure

Ectopic production

Bronchogenic (e.g.,carcinoma)GonadoblastomaHypopharynxOvarian dermoid cystRenal cell carcinomaTeratoma

BreastfeedingBreast stimulationHypothyroidismMedications

Oral contraceptive pills

AntipsychoticsAntidepressantsAntihypertensives

Histamine H2

receptor

blockersOpiates, cocaine

Prolactin > 100 ng per mLEmpty sella syndromePituitary adenoma

HypergonadotropichypogonadismGonadal dysgenesis

Turner's syndrome*Other*

Postmenopausal ovarian failurePremature ovarian failure

AutoimmuneChemotherapyGalactosemiaGenetic17-hydroxylasedeficiency syndromeIdiopathicMumpsPelvic radiation

Hypogonadotropichypogonadism

Anorexia or bulimia nervosa

Central nervous system tumorConstitutional delay of growthand puberty*Chronic illness

Chronic liver diseaseChronic renalinsufficiencyDiabetesImmunodeficiencyInflammatory boweldiseaseThyroid diseaseSevere depression or

psychosocial stressorsCranial radiation

Hypogonadotropic hypogonadism(continued)Excessive exerciseExcessive weight loss or malnutritionHypothalamic or pituitary destructionKallmann syndrome*Sheehan's syndrome

NormogonadotropicCongenital

Androgen insensitivitysyndrome*Mllerian agenesis*

Hyperandrogenic anovulationAcromegalyAndrogen-secreting tumor(ovarian or adrenal)Cushing's diseaseExogenous androgensNonclassic congenital adrenal

hyperplasiaPolycystic ovary syndromeThyroid disease

Outflow tract obstructionAsherman's syndromeCervical stenosisImperforate hymen*Transverse vaginal septum*

OtherPregnancyThyroid disease

*-Causes of primary amenorrhea only.Information from references 3, 6, and 15.


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Abnormal MenstruationAbnormal MenstruationHeres what you need to remember!!Heres what you need to remember!!

Always R/O pregnancy, check papAlways R/O pregnancy, check pap

Try to differentiate anovulatory from ovulatory bleedingTry to differentiate anovulatory from ovulatory bleeding

Good history and physical is key( this applies toGood history and physical is key( this applies toamenorrhea as well)amenorrhea as well)

Do a focused work up based on your H & P rather than aDo a focused work up based on your H & P rather than arandom set of studiesrandom set of studies

In amenorrhea, where no indication of cause based onIn amenorrhea, where no indication of cause based on

H & P, follow the stepwise algorithm for diagnosisH & P, follow the stepwise algorithm for diagnosis

Know the INDICATIONS for endometrial samplingKnow the INDICATIONS for endometrial sampling


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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.

menstrual disorders[1]

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