Menstrual Disorder

N.SmidtN.Smidt--AfekAfek MD MHPE Lake Placid January 2011 The

two phases: follicular and luteal Normal

Regular menstruation 28+/28+/--7days;7days; Flow 4 --7d. 40ml loss Menstrual Disorders

 Abnormal Beleding –– Menorrhagia ,Metrorrhagia, Polymenorrhagia, , --  –– Primary Dysmenorrhea, secondary Dysmenorrhea  Pre Menstrual Tension –– PMD, PMDD Abnormal Uterine Beleeding Abnormal Bleeding Patterns

 Menorrhagia --bleedingbleeding more than 80ml or lasting >7days  Metrorrhagia --bleedingbleeding between periods  Polymenorrhagia -- menses less than 21d apart  Oligomenorrhea --mensesmenses greater than 35 dasy apart. (in majority is anovulatory)  Amenorrhea --NoNo menses for at least 6months Dysfunctional Uterine Bleeding

 Clinical term referring to abnormal bleeding that is not caused by identifiable gynecological pathology  "Anovulatory Uterine Bleeding“ is usually the cause  Diagnosis of exclusion Anovulatory Bleeding

 Most common at either end of reproductive life

 Chronic spotting  Intermittent heavy bleeding Post Coital Bleeding

 Cervical ectropion ( most common in )   Vaginal or cervical malignancy  Common Causes by age

 Neonatal  Premenarchal ––EstrogenEstrogen withdrawal ––ForeignForeign body ––Trauma,Trauma, including sexual abuse Infection ––UrethralUrethral prolapse ––Sarcoma botryoides ––Ovarian tumor ––PrecociousPrecocious Common Causes by age

 Early postmenarche (hypothalamic immaturity) Bleeding diathesis Stress (psychogenic, exercise induced) Pregnancy  years Pregnancy OCs, Trauma Infection  Perimenopause Decline in ovarian function during Superimposed pathology (polyps, neoplasia etc) abnormal uterine bleeding in the premenopausal women

Anovulatory UB Bleeding PregnancyPregnancy--relatedrelated problems Thrombocytopenia von Willebrand's disease Infection Leukemia Cervicitis Endocrine disorders Ovarian problems Trauma Cyst Malignant Tumors Tumor Cervical Endometrial Systemic disease Ovarian mellitus Benign pathology Renal disease Systemic lupus erythematosus Leiomyoma Medications Hormonal,Anticoagulants, platelet inhibitors Androgens, History History

 Can help to distinguish between the 4 common causes: –– Pregnancy ––AbnormalAbnormal endocrine control ––GynecologicGynecologic pathology ––SystemicSystemic disease History

 Patient’s age  Onset of Menarche  Prior menstrual history  Contraceptive and sexual history  Symptoms of systemic disease. Menstrual record chart Physical Examination Physical Examination  Growth parameters  Thorax/ –– Short stature –– Shield chest, –– Obesity (BMI > 30 –– widely spaced nipples kg/m2) –– Galactorrhea –– Underweight (BMI  Abdomen <18.5)Arm span >height –– Abdominal/pelvic mass plus 5 cm  Tanner staging  Skin and hair –– Low for both and –– Acanthosis nigricans pubic hair –– Abnormal bleeding –– High for both breast and (bruises, petechiae) pubic hair –– Striae –– Divergent –– Hyperpigmentation,  External genitalia vitiligo –– –– Low hair line –– Clitoromegaly –– Hirsutism, acne, malemale-- pattern balding –– Perineal trauma  Neck –– , –– Thyroid enlargement –– genital ulcer, –– Webbed neck –– condyloma lata Imperforated Hymen

Check yourself

 Short stature  Turner syndrome, hypothalamichypothalamic--pituitarypituitary disease  Obesity (BMI > 30 kg/m2)  Polycystic ovary syndrome (PCOS)  Underweight (BMI <18.5)  Hypothalamic amenorrhea secondary to , exercise, or weight loss from systemic disease  Arm span >height plus 5 cm  Delayed epiphyseal closure secondary to hypogonadism Check yourself

 Acanthosis nigricans  PCOS, insulin resistance  Abnormal bleeding (bruises, petechiae)  Bleeding diathesis  Striae  Cushing syndrome  Hyperpigmentation, vitiligo  Adrenal insufficiency  Low hair line  Turner syndrome  Hirsutism, acne, malemale--patternpattern balding  Hyperandrogenism (PCOS, CAH, androgenandrogen--secretingsecreting tumor, Check yourself

 presence of Y chromosome)  Thyroid enlargement  Hypothyroidism, hyperthyroidism  Webbed neck  Turner syndrome  Shield chest, widely spaced nipples  Turner syndrome  Galactorrhea  Hyperprolactinemia  Abdominal/pelvic mass  Ovarian tumor, Check yourself

Tanner staging  Low for both breast and pubic hairDelayed sexual development (ie, constitutional delay of puberty)  High for both breast and pubic hairNormal progression of puberty Check yourself

 External genitalia  Imperforate hymenImperforate hymen  ClitoromegalyHyperandrogenism (PCOS, CAH, androgen --secreting tumor, presence of Y chromosome)  Perineal traumaSexual abuse  Vaginal discharge, genital ulcer, condyloma lata  Sexually transmitted infection Initial Approach to Abnormal Uterine Bleeding in Premenopausal Patients (K.Oriel, S.Schrager AFP , 1999) Initial Approach to Abnormal Uterine Bleeding in Perimenopause patients Menorrhagia

 Bleeding disorder  systemic illness  endocrine disorders  structural lesions  Anovulatory Metrorrhagia

 Exogenous hormones  Infections  Polyps, Ectropion  Foreign bodies  abuse Management --MenorrhagiaMenorrhagia

I.I. Medical treatment  Hormonal: COC, Progesterone ( Norethindrone acetate (5 to 10 mg), or Micronized progesterone (200 mg) A.A. NSAIDs

B.B. Hemostatic medications ( Aminocaproic acid )) C.C. Progesteron Releasing IUD D.D. Gonadotrophin releasing hormone agonist Management --MenorrhagiaMenorrhagia

 Surgical Treatment  D&C   Amenorrhea

 Primary ––MenarcheMenarche 14.5 age of 95 thth percentile in US ––CongenotalCongenotal and anatomical defects  Secondary ––PregnancyPregnancy ––PCOPCO ––HormonalHormonal causes ––AcquiredAcquired ablation or scarring of Approach to Oligomenorrhea in Adolescents Uptodate 2010 Other Menstrual related “disorders”

 Dysmenorrhea ––PrimaryPrimary –– Secondary  Premenstrual physical symptoms  (PMS), Premenstrual dysphoric disorder (PMDD), Primary Dysmenorrhea

 More common in adolescence (decreases with age)  Only in ovulatory periods  Some risk factors  PathogenesisPathogenesis--“Uterine“Uterine angina”  Symptoms : lower abd pain, N&V, HA, fatigue, malaise.  Tx: NSAIDs Major causes of secondary dysmenorrhea  Nongynecologic Gynecologic disorders disorders  Endometriosis  Inflammatory bowel  Adenomyosis disease  Ovarian cysts  Irritable bowel  Pelvic adhesions syndrome  Pelvic inflammatory disease  Uteropelvic junction  Uterine polyps obstruction  Congenital obstructive  Psychogenic disorders müllerian malformations  Cervical stenosis ExaminationExamination--SecondarySecondary Dysmenorrhea

 Tenderness, thickness, nodularity at uteroutero--sacralsacral ligament,enlarged  Lateral displacement of  Cervical stenosis  Adnexal enlargement from an Endometriosis clue: red hair color; scoliosis; and dysplastic nevi TreatmentTreatment--SecondarySecondary Dysmenorrhea

 Treat the underlying cause  NSAID’s  Hormonal contraceptives  PrePre--sacralsacral neurectomy in selected cases  Surgery for specific pathology PMS & PMDD Symptoms of PMS Behavioral Psychological Physical

 Mood lability (81)  Irritability ((9191))  Fatigue ((9292))  Food cravings (78)  Fatigue ((9292))  ((9090))  Increased  Anxiety/tension  Breast appetite (70) ((8989)) tenderness ((8585))  Oversensitivity  Depression ( 8080 ))  Acne ( 7171 )) (69)  Forgetfulness  Swelling ((6767))  Anger (67) ((5656))  Headache ((6060))  Crying easily (65)  Poor  GI symptoms  Feeling isolated concentration ((4848)) ((4747)) (65)  Hot flashes ((1818))  Heart palpitations ((1414))  Dizziness ((1414 ))

Definitions of PMS & PMDD

 PMS -- Recurrent psychological or physical symptoms during the of menstrual cycle, resolves by the end of menstruation, and interferes with some aspect of function.

 Premenstrual Dysphoric Disorder (PMDD) --moremore severe form of PMS meeting DSMDSM--IVIV criteria .. Premenstrual Disorders Etiology

 Cause is unknown!

 Interactions of ovarian hormones with neurotransmitters ––AlterationsAlterations of serotoninergic and GABAnergic activity in the brain.

 Imbalance between and Progesterone levels

 Serotonin deficiency

 Effects of hormone shift on endogenous opiods

 Biologic, physiologic, environmental and social factors all seems to be contributory

 Genetic factors seems to play a role.

PMDD

 DSMDSM--VV criteria: ––>> 5 symptoms of PMS 1 week prior to and resolve during menses ––>>11 psychological symptom x 1 year during most cycles  Depressed mood, increased sensitivity, anxiety, irritability ––InterferesInterferes with social, occupation, sexual or schooschooll functioning ––SymptomsSymptoms discretely related to menstrual cycle and not a worsening of a psychiatric or medication condition –– Documented symptoms meeting criteria for at least 3 cycles Occur in luteal phase

Resolves near the start of menstruation

Creates problems or impairment

Not better explained by another diagnosis

Johnson SR. Obstet Gynecol. 2004; Rapkin AJ. Am J Manag Care. 2005; ACOG. ACOG Practice Bulletin No. 15. 2000; Dickerson LM et al. Am Fam Physician. 2003. Treatment approach

 General advice about diet, exercise & stress reduction should be considered before starting specific treatment

 Women with marked underlying psychopatology should see a psychiatrist

 Symptom diary should be used to assess the effect of treatment Eat frequent and smaller portions of foods high in complex carbohydrates

Johnson SR. Obstet Gynecol . 2004. Treatment Of PMSPMS-- Behavioral

 Aerobic exercise/Yoga  Relaxation and stress management  Anger management  SelfSelf--helphelp support groups  Therapy (individual, couples, cognitivecognitive-- behavioral, )  Smoking cessation  Regular sleep  Selective serotonin rere--uptakeuptake inhibitors (SSRI) ....e.g Fluoxetine significantly reduces tension, irritability & dysphoria (4(4--66 times better )  Progestogens  COCP  Diuretics  Antidepressants  danazole  GnRH A Pharmacological

 Selective serotonin rere--uptakeuptake inhibitors (SSRI) ( Fluoxetine significantly reduces tension, irritability & dysphoria ,4,4--66 times times better )  COCP  Diuretics  Other Antidepressants  Danazole  GnRH A Surgical

 Hysterectomy & BSO Premenstrual Disorders Management

 ACOG recommends the serotoninergic antidepressants as the firstfirst--lineline treatment of choice for severe PMS and PMDD. (Evidence level C)

 The US FDA approved use of fluoxetine and sertraline for women with PMDD Cases Case 11--LilyLily

 A 28 year old lady comes to see you as she is tired of having heavy periods.  She says she has always had heavy and painful periods for a long time but is finally at the end of her tether with them.

 What do you do first? History

 Frequency of bleeding: --HasHas to change and pad every 22--33 hrs --hashas flooded several times and is always worried aaboboutut this. --BleedsBleeds heavily for 4 days.  Menstrual cycle: regular 28 day cycle, bleeds for 6 days.  only when menstruating  No IMB  No , No PCB  No discharge  Married for 8 yrs, no other partners.  Smear aged 25 --normalnormal  PMH: Non significant  SH: smoker  FH : Nonl significant. Would you examine her?

 Abdominal examination ––YESYES  Pelvic exmination +/_  Cultures +/ --

 O/E: Abdomen soft, no tenderness or masses. What investigations would you request?

 CBC+DiffCBC+Diff––indicatedindicated in all women with  Coagulation –– only indicated if heavy bleeding since menarche, other symptoms or F/H.  Routine Thyroid and Iron studies are not required unless clinically indicated. What management options would you offer?

1.1. LevonorgestrelLevonorgestrel--releasingreleasing intrauterine system. 2.2. Aminocaproic acid 3.3. NSAIDs 4.4. COCPs. Oral (northisterone) or Injected progestogen. Case 22--AmandaAmanda

 30 y/o. Had the Mirena IUD put in one month ago for heavy menstrual bleeding.  Before this she was on the COC which did not control her periods.  Unfortunately she presents today because the IUD was expelled a few days ago.  She said this was because her bleeding was so heavy.  She is now on her fourth day of her heavy period & suffering mild discomfort. She goes through 10 pads per day & has passed a few small clots.  She said she had to take 2 days off work because she had to change her pads so often, was fearful of accidents & had pain.  She wants something done about her periods.  She is adamant that she does not want another Mirena inserted as she feels it won’t work.

 What other treatments could you offer her? Management options

 Tranexamic acid  NSAIDs  COC  Oral progesterones  Injected/implanted progesterones.  Consider referral to a specialist. Cont.

 She now decides that she does not want any further hormonal treatment as when she was on the pill, she noticed severe changes in her mood & breast tenderness.

 After discussion of all the options, you both agree a trial of Hexacaproic acid.  You also organise a pelvic US scan.

 She tries Hexacaproic acid for 3 months.  3 months later she comes back and says that hexacaproic acid has made very little difference to her periods.

 Her US was normal.

 She has been discussing matters with her mother who had a hysterectomy in her 30s.

 She says she would like to be referred for a hysterectomy.  What could you do next?

 Discuss another less invasive technique such as ablation

 Make a referral endometrial ablation

 Endometrial ablation should be considered in women: ––wherewhere bleeding has a severe impact on QoL & they do not want to conceive in future –– with HMB who have a normal uterus & with small uterine fibroids(<3cm in diameter) ––preferentiallypreferentially to a hysterectomy alone when the uterus is no bigger than 10/40 & suffer from HMB alone  Women must be advised to avoid subsequent pregnancy & the need to use effective contraception, if required Case 33--CheriseCherise

 41y/o. G2P2  comes to see you with a 12 m h/o increasingly heavy and painful periods significantly affecting her quality of life.  No dysuria, frequency or incontinence  LMP 2 weeks ago, Menstrual cycle: 7/28  Normal PAP 2m ago  PMH: Non significant  FH: Grandmother had fibroids What would you do next?

 Abdominal and  Obtain swabs for infection

 O/E: Abdominal exam: Suprapubic uterine mass. Pelvic examination reveals a bulky uterus.

 You suspect she has uterine fibroids however cannot at this stage rule out anything more sinister. Investigations

 Pregnancy Test (Neg)  Urine Dipstix (Normal)  H/H 11.2/31.5  US. first line investigation for detecting structural abnormalities confirms large uterine fibroids, the largest being 3.6cm diameter  ––onlyonly if USS inconclusive Do you refer?

 Yes:

 “Women with fibroids that are palpable abdominally or who have intracavity fibroids and/or whose uterine length as measured at or hysteroscopy is greater than 12 cm should be offered immediate referral to a specialist.”  What management should she be offered next?

 Endometrial Ablation? No, --ThisThis can be offered to women with small fibroids <3cm diameter Management options

 Uterine Artery Embolisation

-- for women who want to preserve uterus and avoid surgery. May remain fertile.  Myomectomy

 -- for women who want to preserve uterus. May remain fertile.  Hysterectomy

-- if other treatments fail, if the women no longer wishes to retain her uterus or fertility -- Case 44--JoanJoan

 20 y/o. G0P0  Episodes of irritability and moodiness, Lead to huge arguments with her boyfriend.  Sleeps away the day and miss school or work.  Bloated, tired and hungry during the days just prior to menses  Her boyfriend jokes and makes offoff--thethe-- wall remarks about PMS.  She comes to you for advice.  Prefers “Natural” treatment Natural Treatment

 Agnus castus fruit extract ——(the(the Chasteberry tree)  Vitamin B6  Vitamin E  Calcium, and Magnesium  Complex carbohydratecarbohydrate--richrich beverage  Bright light therapy

 Non effective: Progesterone, evening primrose oiloil [[7373 ], essential free fatty acids [ 7474 ], and ginkgo biloba extract Thank you all and…