Menarche to menopause

ALL ABOUT MENTRUATION ABNORMALITIES

1. Menarche to
Menopause
DR.DIVYA JAIN
INDORE

3. Menstruation
Shedding the uterine lining
(endometrium) if pregnancy does not
occur.
Necessary (in the absence of
hormonal regulation) to insure the
endometrium does not become
hyperplastic.

4. Normal Menstrual
Cycles
Mature, ovulatory women
–28-29 day average
–21-36 day range
–2-7 days duration
–20-80 cc of blood loss per month

5. Cycle Variation
Women in their middle reproductive
years have the most predictable cycles
More pronounced cycle to cycle
variability in the 5-7 years after
menarche and 6-8 years before
menopause

6. Cycle Variation (cont.)
Adolescents
–Majority range 21-48 days
–Usually anovulatory
–Mean time from menarche until half the cycles
are ovulatory depends upon the age of
menarche
–12 yrs 1yrs till half cycles are ovulatory
–12-13 3yrs
–>13 4.5 yrs

7. Cycle Variation (cont.)
Perimenopause
–Cycles initially shorten
–Ultimately (apparently) lengthen, as an
entire cycle will be skipped
Average age of menopause is 51
–Cessation of menses for one year

9. Abnormal Uterine
Bleeding
Menorrhagia
Oligomenorrhea
Metrorhhagia
Polymenorhhea
Menometrorhhagia
Oligomenorrhea
Contact bleeding

10. Terminology
Amenorrhea—lack of menstrual bleeding
–Primary—no menses by age 16
–Secondary—absence of 3 or more expected
menstrual cycles
Break-through bleeding (BTB) unexpected
bleeding usually occurring while a woman is
on exogenous hormonal medication (eg
OCPs, patch, or ring)

11. Terminology (cont.)
Menorrhagia—heavy menstrual bleeding.
Prolonged or excessive menstrual blood
loss with regular cycles
Metrorrhagia—irregular, frequent bleeding
Menometrorrhagia—irregular menses with
prolonged or excessive blood loss
Midcycle bleeding—light menstrual
bleeding occurring in ovulatory women at
the midcycle estradiol trough

12. Terminology (cont.)
Oligomenorrhea-- menstrual
bleeding/menses occurring less frequently
than 36 days apart
Polymenorrhea—frequent menstrual
bleeding/menses occurring more frequently
than 21 days apart
Contact bleeding/post-coital bleeding
Dysmenorrhea- painful menstrual bleeding

13. Impact on Health
75% of women experience physical changes
associated with menses
PMS (Premenstrual syndrome)
PMDD (Premenstrual dysphoric disorder)
Direct and indirect health care costs
–Visits to ED, clinic, or office
–Time lost from work

14. PMS
Psychoneuroendocrine d/o with
biological, social and psychological
impacts
Up to 75% of women experience some
level of recurrent sx
Up to 5% may experience severe sx
and distress

15. Common PMS
Symptoms
Headache
Breast pain
Bloating
Irritability
Fatigue
Crying
Abd pain
Clumsiness
Sleep alteration
Labile mood
Social withdrawal
Libido change
Appetite change

16. Requisite Symptoms
for PMDD Diagnosis
Depressed mood
Anxiety/tension
Mood swings
Irritability
Decreased interest
Concentration
difficulties
Fatigue
Appetite changes/food
cravings
Insomnia/hypersomnia
Feeling out of control
Physical symptoms
5/11 symptoms
needed for
diagnosis and
Sx disrupt daily
functioning

17. PMS/PMDD Tx
Limit caffeine, tobacco, alcohol and
sodium
Frequent high-complex carb meals
CBT, stress management, aerobic
exercise

18. Dysmenorrhea
Painful menstruation- when pain
prevents normal activity and requires
medication
Pain starts when bleeding starts
Prostaglandin activity
Emotional/psychological factors

19. Dysmenorrhea tx
NSAIDs, starting a day before period
–Ibuprofen, naproxen
Anti-prostaglandins much less
effective after pain is established
Continuous heat to abd
OCPs for 6-12 months have lasting
benefit

20. Ddx of Abnormal
Uterine Bleeding
Blood Dyscrasias
Anatomic causes of bleeding,
including pregnancy
Anovulation
Malignancy
Non-uterine causes of bleeding

21. AUB work-up
Hx
PE with cytology
Pelvic ultrasound
Endometrial biopsy
Hysteroscopy
D & C

24. Leiomyomas (Fibroids)
Benign neoplasms arising from uterine wall
smooth muscle cells
20-25% of reproductive age women
Can be small to quite large, single or
multiple. Surrounded by pseudocapsule.
Often asx, but can cause metrorrhagia,
menorrhagia, dysmenorrhea and infertility
Cause unknown, but hormone responsive

25. Fibroid Tx
Depends on sx, age, parity,
reproductive plans, general health,
and size/location of leiomyomas
GnRH agonists- to shrink fibroid
OCPs control bleeding but do not treat
the fibroid
Progestin-releasing IUD for multiple
small leiomyomata

26. Fibroid Tx - Surgical
Myomectomy- preserves fertility, high risk
for fibroid recurrence
Hysterectomy- eliminates sx and chance of
recurrence. Also eliminates uterus.
Uterine fibroid embolization (UFE)
–Embolic occlusion of uterine arteries
–As effective as above, few recurrences, few
major complications

27. Anovulation
Patient History—very important to
diagnosis
–Ovulatory cycles—consistent number of
days from beginning of one cycle to the
next, breast tenderness, and
dysmenorrhea usually present
–Anovulatory cycles—variation in
number of days per cycle, no breast
tenderness, and dysmenorrhea is not
consistent from one cycle to the next

28. DUB
“Dysfunctional uterine bleeding”
Abnormal uterine bleeding with
pathologic causes ruled out
So..you’ve done all that stuff, and it’s
all okay
Usually tx with hormones (ie OCPs) to
control bleeding

29. Non-uterine causes
Genital neoplasms of the vulva or vagina
–To avoid missing vaginal lesions, stainless steel
speculum blades should be rotated on removal
to fully evaluate the vaginal mucosa
–Better: use plastic speculum with good light
source
Genital trauma/foreign objects
Rectal bleeding or urinary tract source

30. Evaluation
History
–Menstrual pattern (duration, changes in
quality, color of menses)
–Dysmenorrhea, mittleschmerz, breast
changes
–Post-coital spotting
–Dietary practices, change in weight,
exercise, stress
–Evidence of systemic disease

31. Evaluation (cont.)
Physical Exam
–Vital signs, height, weight, body phenotype, BMI
–Skin, hair (acne, hirsutism pattern)
–Fat distribution, striae
–Thyroid
–Breast exam to check for galactorrhea
–Complete pelvic exam
–Tanner stage for teens

32. Evaluation--testing
All patients:
–Pregnancy test
–CBC with platelets
–Recent Pap
Over 35 yrs:
–Endometrial sample
Documented drop in
hgb <10
–PT, PTT
–Bleeding time
As indicated:
–TSH
–Prolactin
–Testosterone
–LH/FSH
–17-OH progesterone
–Overnight
dexamethasone
suppression test or 24
hr urinary free cortisol
–Hysteroscopy or
ultrasound

33. Acute Bleeding: Control
Oral progestins:
–Micronized Progesterone 200 mg (Prometrium)
or Medroxyprogesterone 10 mg (Provera) or
Norethindrone 5 mg (Aygestin)
–1 po q4 hrs or until bleeding stops, then
–1 qid x 4 days
–1 tid x 3 days
–1 bid x 2 weeks, then
–Cycle monthly with progestin or low dose oral
contraceptive

34. AUB Long Term Control
Cycle with low dose OCP, patch, or vaginal
ring
Cycle with a progestin, eg Prometrium
Use of progestin-containing IUD (Mirena)
Choice depends upon:
–Contraceptive need
–Smoking status
–Medical history
–Patient preference

35. Endometriosis
Abnormal growth of endometrial tissue
in locations other than the uterine
lining
3-10% of women of reproductive age
30% of infertile women

36. E

38. Tx
Analgesics (ibu)
Hormones
–OCPs or progestins
–Danazol- prevents gonadotropin release, inhibits
midcyle LH and GSH. Androgenic side fx
–GnRH agonists (Lupron)- with continuous admin,
suppresses gonadotropin secretion
Assisted reproduction when desired

39. Amenorrhea
Absence of menses
Primary amenorrhea- no menses by age 16
with otherwise nl development
Secondary amenorrhea- absence of
menses for 3 or more cycles or 6 months in
a previously menstruating female
–MC cause??
–3% in genl population
–100% under extreme stress
Examples?

40. Tx
Desiring pregnancy?
–Ovulation induction
Not desiring pregnancy?
–If hypoestrogenic, combo tx with estrogen and
progesterone to maintain bone density and
prevent genital atrophy
–Normal progestin challenge: needs occasional
progestin to prevent endometrial hyperplasia and
cancer
–OCPs work well for either, and can decrease
hirsutism
–Calcium, too!

41. THANK THANK
YOUYOU