MENSTRUAL DISORDER 2 ( revised and upload) .ppt

menstrual cycle abnormality

1. Menstrual Disorders
Geetha Kamath, M.D.
Dept. of Medicine
West Virginia University

2. Definition
Normal menstrual cycle involves hypothalamus-
pituitary-ovary and uterus and is 28 days
Vaginal bleeding is abnormal (Abnormal Uterine
Bleeding--AUB) when:
Volume is excessive or
Occurs at times other than expected, including
during pregnancy or menopause
Known as dysfunctional uterine bleeding (DUB)
when organic causes are excluded

3. AUB
Duration >7 days or
Flow >80ml/cycle or
Occurs more frequently than 21 days or
Occurs more than 90 days apart or
Intermenstrual or postcoital bleeding

4. Terminology
Menorrhagia: excessive flow
Menometrorrhagia: excessive volume
Oligomenorrhea: scanty flow
Dysmenorrhea: painful menstrual cycles

5. Causes of Menstrual Disorders
Structural
Pregnancy associated
Hormonal and endocrine
Hematologic and coagulation disorders
Other

6. Causes--structural
Endometrial polyps
Endometrial hyperplasia
Endometritis
Fibroids
Intrauterine devices
Uterine arterio-venous malformation (AVM)
Uterine sarcoma

7. Pregnancy related
Implantational bleeding
Ectopic pregnancy
Spontaneous abortion [incomplete, missed,
septic, threatened]
Therapeutic abortion
Gestational trophoblastic disease

8. Hormonal and Endocrine causes
Anovulatory (including polycystic ovary
syndrome)
Ovarian cyst
Estrogen-producing ovarian tumor
Perimenopause
Hormonal contraceptives
Hormone Replacement Therapy
Hypothyroidism

9. Hematologic
Von Willebrand’s disease (most common
inherited bleeding disorder with frequency
1/800-1000)
Hemophilia
Thrombocytopenia
Hematologic malignancies (leukemia)
Liver disease

10. Other
DUB (dysfunctional uterine bleeding): non-organic
causes, either ovulatory or anovulatory
Fallopian tube cancer
Trauma
Foreign body
Cervical bleeding--mets, cervicitis, cervical cancer
Vaginitis--atrophic, cancer of vagina
Endometrial cancer (10% of post-menopausal
bleeding)

11. Evaluation of Abnormal Uterine
Bleeding (AUB)
Acute
History suggestive of:
Pregnancy and related
complications
Recent and Heavy
bleeding
Pelvic pain
Medications contributing
to above
Chronic
History:
Long standing abnormal
menstrual history
Symptoms of anemia,
hypothyroidism,
perimenopause
Personal or family history of
excessive bleeding

12. AUB Examination
Assess vitals/hemodynamic stability
Look for features of anemia (pallor, tachycardia,
syncope)
Look for features of hypothyroidism
Look for metabolic syndrome (obesity,
hirsutism, acne)
Pelvic exam for structural abnormalities:
fibroids, pregnancy, active bleeding—uterine vs.
cervical bleeding

13. AUB Lab Studies
Serum HCG to rule out pregnancy
CBC and iron studies to assess severity of anemia
TSH for thyroid disorders
Coagulation studies (PT, PTT, platelet count, VWF) (primarily
for adolescents)
Transvaginal ultrasound to look for fibroids and other
masses/lesions
Endometrial biopsy to rule out endometrial cancer in
perimenopausal and chronic anovulatory cycles (primarily for
women >35 years with AUB and postmenopausal women)
Sonohysterography is useful in diagnosis of anatomical lesions
which might even be missed with transvaginal ultrasound

14. Treatment of Chronic Menorrhagia
for Most Causes (including DUB)
Combined hormonal contraceptives (cyclical or
continuous)
DMPA (depot medroxyprogesterone)
IUD (Intrauterine devices)

15. Treatment options continued
After excluding coagulopathy, pregnancy, or
malignancy:
Progestins
Estrogens including oral contraceptives
Cyclic NSAIDS
Dilatation and curettage (surgical)
Endometrial ablation (surgical)
Hysteroscopic endometrial resection (surgical)

16. Treatment for Fibroids
Surgical: Hysterectomy/myomectomy, uterine
artery ablation
Medical: Suppression of gonadotropins (danazol
and leuprolide)

17. Treatment: progestins
Inhibits endometrial growth by inhibiting
synthesis of estrogen receptors, promotes
conversion of estradiol to estrone, inhibits LH
Organized slough to basalis layer
Stimulates arachidonic acid production
Progestins preferred for those women with
anovulatory AUB

18. Progestational Agents
Cyclic medroxyprogesterone 2.5-10mg daily for
10-14 days
Continuous medroxyprogesterone 2.5-5mg daily
DMPA 150 mg IM every 3 months
Levonorgestrel IUD (5 years)

19. Estrogens
Conjugated estrogens given IV every 6 hours
effective in controlling heavy bleeding followed
by oral estrogen
For less severe bleeding, oral conjugated
estrogens 1.25 mg, 2 tabs qid--until bleeding
stops

20. NSAIDS
Cyclooxygenase pathway is blocked
Arachidonic acid conversion from
prostaglandins to thromboxane and prostacyclin
(which promotes bleeding by causing
vasodilation and platelet aggregation) is blocked

21. Clinical Highlights
Most common cause of AUB in reproductive
age is pregnancy related--so initial evaluation
must include pregnancy test.
Pregnancy must be ruled out before initiating
invasive testes or medical therapy

22. Clinical Highlights
Endometrial biopsy is recommended for post
menopausal women
Or
Younger women with history of chronic
anovulation >35 years of age

23. Clinical Highlights
Uterine cancer and endometrial hyperplasia must
be ruled out before medical therapy is initiated
in postmenopausal/perimenopausal bleeding
NSAIDS may reduce menstrual flow by 20-60%
in women with chronic menorrhagia
Coagulopathy workup must be initiated in
menorrhagia in adolescents

24. References
ACOG Practice Bulletin #14, 2000
American Journal Obstetrics and Gynecol
2005;193:1361
Clinical Obstetrics & Gynecology 50(2):324-353,
June 2007
Comprehensive Gynecology, 4
th
edition
Harrison’s Principles of Internal Medicine, 14
th
edition
Karlsson, et al, 1995