Menstrual Disorder
N.SmidtN.Smidt--AfekAfek MD MHPE Lake Placid January 2011 The Menstrual Cycle
two phases: follicular and luteal Normal Menstruation
Regular menstruation 28+/28+/--7days;7days; Flow 4 --7d. 40ml loss Menstrual Disorders
Abnormal Beleding –– Menorrhagia ,Metrorrhagia, Polymenorrhagia, Oligomenorrhea, Amenorrhea -- Dysmenorrhea –– 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 pregnancy) Cervicitis Vaginal or cervical malignancy Polyp Common Causes by age
Neonatal Premenarchal ––EstrogenEstrogen withdrawal ––ForeignForeign body ––Trauma,Trauma, including sexual abuse Infection ––UrethralUrethral prolapse ––Sarcoma botryoides ––Ovarian tumor ––PrecociousPrecocious puberty Common Causes by age
Early postmenarche Anovulation (hypothalamic immaturity) Bleeding diathesis Stress (psychogenic, exercise induced) Pregnancy Menarche years Pregnancy OCs, Trauma Infection Perimenopause Decline in ovarian function during menopause 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 Endometritis Ovarian problems Trauma Cyst Malignant Tumors Tumor Cervical Endometriosis Endometrial Systemic disease Ovarian Diabetes mellitus Benign pathology Renal disease Cervical polyp Systemic lupus Endometrial polyp erythematosus Leiomyoma Medications Adenomyosis Hormonal,Anticoagulants, platelet inhibitors Androgens, spironolactone 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/breasts –– 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 breast and –– Acanthosis nigricans pubic hair –– Abnormal bleeding –– High for both breast and (bruises, petechiae) pubic hair –– Striae –– Divergent –– Hyperpigmentation, External genitalia vitiligo –– Imperforate hymen –– Low hair line –– Clitoromegaly –– Hirsutism, acne, malemale-- pattern balding –– Perineal trauma Neck –– Vaginal discharge, –– 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 eating disorder, 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, hematocolpos 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 Endometrial ablation Hysterectomy 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 endometrium Approach to Oligomenorrhea in Adolescents Uptodate 2010 Other Menstrual related “disorders”
Dysmenorrhea ––PrimaryPrimary –– Secondary Premenstrual physical symptoms premenstrual syndrome (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 uterus Lateral displacement of cervix Cervical stenosis Adnexal enlargement from an endometrioma 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)) Bloating ((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 luteal phase 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 Estrogen 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 tampon 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. Pelvic pain only when menstruating No IMB No dyspareunia, 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 heavy menstrual bleeding 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 progestogen (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 pelvic examination 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 Hysteroscopy ––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 ultrasound 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…