Menstrual Disorder

N.Smidt-Afek MD MHPE
N.SmidtLake Placid January 2011

The Menstrual Cycle

two phases: follicular and luteal

Normal Menstruation

Regular

menstruation 28+/28+/-7days;

Flow 44-7d. 40ml loss

Menstrual Disorders

Abnormal Beleding
Menorrhagia ,Metrorrhagia,
Polymenorrhagia, Oligomenorrhea,
Amenorrhea-Amenorrhea

Dysmenorrhea
Primary Dysmenorrhea, secondary
Dysmenorrhea

Pre Menstrual Tension

PMD, PMDD

Abnormal Uterine
Beleeding

Abnormal Bleeding Patterns

Menorrhagia-bleeding more than 80ml or lasting >7days

MenorrhagiaMetrorrhagia--bleeding between periods
Metrorrhagia
Polymenorrhagia-- menses less than 21d apart
Polymenorrhagia
Oligomenorrhea--menses greater than 35 dasy apart. (in
Oligomenorrhea
majority is anovulatory)
Amenorrhea-- No menses for at least 6months
Amenorrhea

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
Estrogen withdrawal

Premenarchal
Foreign body
Trauma, including sexual abuse
Infection
Urethral prolapse
Sarcoma botryoides
Ovarian tumor
Precocious 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
Pregnancy--related problems
Pregnancy
Infection
Cervicitis
Endometritis
Trauma
Malignant Tumors
Cervical
Endometrial
Ovarian
Benign pathology
Cervical polyp
Endometrial polyp
Leiomyoma
Adenomyosis

Bleeding
Thrombocytopenia
von Willebrand's disease
Leukemia
Endocrine disorders

Ovarian problems
Cyst
Tumor
Endometriosis
Systemic disease
Diabetes mellitus
Renal disease
Systemic lupus
erythematosus

Medications
Hormonal,Anticoagulants,
platelet inhibitors
Androgens,
spironolactone

History

History

Can help to distinguish between the

4 common causes:

Pregnancy
Abnormal endocrine control
Gynecologic pathology
Systemic disease

History

Patients age
Onset of Menarche
Prior menstrual history
Contraceptive and sexual history
Symptoms of systemic disease.

Menstrual record chart

Physical Examination

Physical Examination

Growth parameters
Short stature
Obesity (BMI > 30
kg/m2)
Underweight (BMI
<18.5)Arm span >height
plus 5 cm
Skin and hair
Acanthosis nigricans
Abnormal bleeding
(bruises, petechiae)
Striae
Hyperpigmentation,
vitiligo
Low hair line
Hirsutism, acne, male
male-pattern balding
Neck
Thyroid enlargement
Webbed neck

Thorax/breasts
Shield chest,
widely spaced nipples
Galactorrhea
Abdomen
Abdominal/pelvic mass
Tanner staging
Low for both breast and
pubic hair
High for both breast and
pubic hair
Divergent
External genitalia
Imperforate hymen
Clitoromegaly
Perineal trauma
Vaginal discharge,
genital ulcer,
condyloma lata

Imperforated Hymen

Check yourself

Short stature
Turner syndrome, hypothalamichypothalamic-pituitary 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-pattern balding
Hyperandrogenism (PCOS, CAH, androgenandrogen-secreting
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, androgenandrogen-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 -Menorrhagia
I.

Medical treatment

A.

Hormonal: COC, Progesterone (Norethindrone

(Norethindrone
acetate (5 to 10 mg), or Micronized
progesterone (200 mg)
NSAIDs

B.

Hemostatic medications (Aminocaproic

(Aminocaproic acid)
acid)

C.

Progesteron Releasing IUD

Gonadotrophin releasing hormone agonist

D.

Management -Menorrhagia

Surgical Treatment

D&C

Endometrial ablation
Hysterectomy

Amenorrhea

Primary
Menarche 14.5 age of 95th percentile in US
Congenotal and anatomical defects

Secondary

Pregnancy
PCO
Hormonal causes
Acquired ablation or scarring of endometrium

Approach to Oligomenorrhea in Adolescents Uptodate 2010

Other Menstrual related

disorders

Dysmenorrhea
Primary
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
Pathogenesis--Uterine angina
Pathogenesis
Symptoms : lower abd pain, N&V,
HA, fatigue, malaise.
Tx: NSAIDs

Major causes of secondary

dysmenorrhea

Gynecologic disorders

Endometriosis



Adenomyosis

Ovarian cysts



Pelvic adhesions

Pelvic inflammatory


disease

Uterine polyps

Congenital obstructive

mllerian malformations

Cervical stenosis

Nongynecologic
disorders
Inflammatory bowel
disease
Irritable bowel
syndrome
Uteropelvic junction
obstruction
Psychogenic disorders

Examination-Secondary
ExaminationDysmenorrhea

Tenderness, thickness, nodularity at

utero--sacral ligament,enlarged
utero
uterus
Lateral displacement of cervix
Cervical stenosis
Adnexal enlargement from an
endometrioma

Endometriosis clue: red hair

color; scoliosis; and
dysplastic nevi

Treatment-Secondary
TreatmentDysmenorrhea

Treat the underlying cause

NSAIDs
Hormonal contraceptives
Pre--sacral neurectomy in selected
Pre
cases
Surgery for specific pathology

PMS & PMDD

Symptoms of PMS
Behavioral

Mood lability (81)

Food cravings (78)
Increased
appetite (70)
Oversensitivity
(69)
Anger (67)
Crying easily (65)
Feeling isolated
(65)

Psychological

Irritability (91
(91))
Fatigue (92
(92))
Anxiety/tension
(89)
89)
Depression (80
(80))
Forgetfulness
(56)
56)
Poor
concentration
(47)
47)

Physical

Fatigue (92
(92))
Bloating (90
(90))
Breast
tenderness (85
(85))
Acne (71
(71))
Swelling (67
(67))
Headache (60
(60))
GI symptoms
(48)
48)
Hot flashes (18
(18))
Heart
palpitations (14
(14))
Dizziness (14
(14)

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) - more severe form of PMS
meeting DSM
DSM-IV criteria
criteria..

Premenstrual Disorders
Etiology

Cause is unknown!

Interactions of ovarian hormones with

neurotransmitters Alterations 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

DSM--V criteria:
DSM
> 5 symptoms of PMS 1 week prior to and resolve
during menses
>1 psychological symptom x 1 year during most
cycles

Depressed mood, increased sensitivity, anxiety,

irritability

Interferes with social, occupation, sexual or school

functioning
Symptoms 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 PMSPMSBehavioral









Aerobic exercise/Yoga
Relaxation and stress management
Anger management
Self--help support groups
Self
Therapy (individual, couples, cognitivecognitivebehavioral, )
Smoking cessation
Regular sleep


Selective

serotonin rere-uptake inhibitors

(SSRI) ....e.g Fluoxetine significantly
reduces tension, irritability & dysphoria
(4
(4--6 times better )

Progestogens

COCP

Diuretics

Antidepressants

danazole

GnRH A

Pharmacological

Selective serotonin rere-uptake inhibitors

(SSRI) ( Fluoxetine significantly reduces
tension, irritability & dysphoria ,4,4-6 times
better )

COCP
Diuretics
Other Antidepressants
Danazole
GnRH A

Surgical

Hysterectomy & BSO

Premenstrual Disorders
Management

 ACOG recommends the serotoninergic

antidepressants as the firstfirst-line 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-Lily

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:
- Has to change tampon and pad every 2
2--3 hrs
- has flooded several times and is always worried about
this.
- Bleeds 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 - normal
PMH: Non significant
SH: smoker
FH : Nonl significant.

Would you examine her?

Abdominal examination YES

Pelvic exmination +/_
Cultures +/+/-

O/E: Abdomen soft, no tenderness or

masses.

What investigations would

you request?

CBC+Diff indicated in all women with

CBC+Diff
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?

Levonorgestrel-releasing
Levonorgestrelintrauterine system.
2. Aminocaproic acid
3. NSAIDs
4. COCPs.
Oral progestogen (northisterone) or
Injected progestogen.
1.

Case 22- Amanda

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 wont 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:
where 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)
preferentially 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- Cherise

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 only 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,

- This 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-Joan

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-thethewall remarks about PMS.
She comes to you for advice.
Prefers Natural treatment

Natural Treatment

Agnus castus fruit extract (the

Chasteberry tree)
Vitamin B6
Vitamin E
Calcium, and Magnesium
Complex carbohydratecarbohydrate-rich beverage
Bright light therapy
Non effective: Progesterone, evening primrose
oil [73],
73], essential free fatty acids [74
[74],
], and
ginkgo biloba extract

Thank you all and