Download Menstrual Disorders

Menstrual Disorders
Geetha Kamath, M.D.
Dept. of Medicine
West Virginia University
Definition
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Normal menstrual cycle involves hypothalamuspituitary-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
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Known as dysfunctional uterine bleeding (DUB)
when organic causes are excluded
AUB
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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
Terminology
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Menorrhagia: excessive flow
Menometrorrhagia: excessive volume
Oligomenorrhea: scanty flow
Dysmenorrhea: painful menstrual cycles
Causes of Menstrual Disorders
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Structural
Pregnancy associated
Hormonal and endocrine
Hematologic and coagulation disorders
Other
Causes--structural
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Endometrial polyps
Endometrial hyperplasia
Endometritis
Fibroids
Intrauterine devices
Uterine arterio-venous malformation (AVM)
Uterine sarcoma
Pregnancy related
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Implantational bleeding
Ectopic pregnancy
Spontaneous abortion [incomplete, missed,
septic, threatened]
Therapeutic abortion
Gestational trophoblastic disease
Hormonal and Endocrine causes
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Anovulatory (including polycystic ovary
syndrome)
Ovarian cyst
Estrogen-producing ovarian tumor
Perimenopause
Hormonal contraceptives
Hormone Replacement Therapy
Hypothyroidism
Hematologic
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Von Willebrand’s disease (most common
inherited bleeding disorder with frequency
1/800-1000)
Hemophilia
Thrombocytopenia
Hematologic malignancies (leukemia)
Liver disease
Other
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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)
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
AUB Examination
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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
AUB Lab Studies
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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
Treatment of Chronic Menorrhagia
for Most Causes (including DUB)
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Combined hormonal contraceptives (cyclical or
continuous)
DMPA (depot medroxyprogesterone)
IUD (Intrauterine devices)
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)
Treatment for Fibroids
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Surgical: Hysterectomy/myomectomy, uterine
artery ablation
Medical: Suppression of gonadotropins (danazol
and leuprolide)
Treatment: progestins
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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
Progestational Agents
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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)
Estrogens
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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
NSAIDS
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Cyclooxygenase pathway is blocked
Arachidonic acid conversion from
prostaglandins to thromboxane and prostacyclin
(which promotes bleeding by causing
vasodilation and platelet aggregation) is blocked
Clinical Highlights
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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
Clinical Highlights
Endometrial biopsy is recommended for post
menopausal women
Or
 Younger women with history of chronic
anovulation >35 years of age
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Clinical Highlights
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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
References
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ACOG Practice Bulletin #14, 2000
American Journal Obstetrics and Gynecol
2005;193:1361
Clinical Obstetrics & Gynecology 50(2):324-353,
June 2007
Comprehensive Gynecology, 4th edition
Harrison’s Principles of Internal Medicine, 14th
edition
Karlsson, et al, 1995