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) ) )91Irritability 91(iibltriratI ( y ) 92)Fatigue 92(tiag ( Fue Food cravings (78) ) 92)Fatigue 92(tiag ( Fue ) 90)Bloating 90(tlgoBi ( an Increased Anxiety/tension Breast appetite (70) ) 89) 89( ( ) 85)tenderness ssenr85(ednte ( Oversensitivity Depression80 ( 80)) Acne71 ( )) 71 (69) Forgetfulness ) 67)Swelling 67(llgeiS ( nw Anger (67) ) 56) 56( ( ) 60)Headache 6 0(echadaeH ( Crying easily (65) Poor GI symptoms Feeling isolated concentration ) 48) 48( ( ) 47) 47( ( (65) ) 8)1Hot 81flashes (sehsflaotH ( Heart ) 4)1palpitations 41(i lttpsiaaonp ( 41Dizziness 41( sDsizezin ( )) 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