Oguchi A. Nwosu M.D. Assistant Profressor Emory Family Medicine Dept. 6/28/07
Menstrual Cycle
Definitions
Menorrhagia Excessive (>80ml) uterine bleeding
Prolonged (>7days) regular
Ovulatory
Regular menstrual cycles (plus premenstrual symptoms such as dysmenorrhea and mastalgia
DUB
-Defn: Excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease -Diagnosis of exclusion - Anovulatory -Usually extremes of reproductive life and in pts with PCOS
DUB pathophysiology
Disturbance in the HPO axis thus changes in length of menstrual cycle No progesterone withdrawal from an estrogen-primed endometrium Endometrium builds up with erratic bleeding as it breaks down.
16year old with daily heavy vaginal bleeding with clots, no cramps
5ft 7in, 105ibs, normal sec. sex xristics, pelvic normal Menarche 14, 2 periods last year, heavy lasts 2 weeks, virginal. I month hx of daily heavy vag bleeding with clots, 8 to 10 pads x day No associated symptoms
Picture of teenager
DUB management
HCG, CBC, TSH ? Coagulation workup Ensure pap smear UTD if appropriate >35 or Ca risk factors, tamoxifen use sample endometrium
DUB management
I/V or I/M conjugated estrogen therapy acute DUB--How ?!!!. Usually followed by OCP or progestin Cyclic progestins for 10 to 12 days each cycle, consider mirena IUD OCP D and C old school, no longer recommended.
Menorrhagia
-Heavy vaginal bleeding that is not DUB -Usually secondary to distortion of uterine cavity- heavy with or without prolongation (anatomic). Uterus unable to contract down on open venous sinuses in the zona basalis -Other causes organic, endocrinologic, hemostatic and iatrogenic -Usually ovulatory
Menorrhagia, Management
History Physical exam-anemia, obesity, androgen excess
e.g. hirsuitism, acne, ecchymosis/purpura, thyroid, galactorrhea, liver/spleen, Pelvic- Uterine, cervical and adnexal
Menorrhagia, management
HCG, CBC, TSH ? Coagulation workup Ensure pap smear UTD if appropriate >35 or Ca risk factors, tamoxifen use sample endometrium Other tests as INDICATED by HX and PE
Sensitivity -100%
OCPs, esp. if contraception desired, up to 60% dec. supp. HP axis Continous OCPs Oral continous progestins (day 5 to 26), most
prescribed, antiestrogen, downregulates endormetrium
GnRH agonists, Inhibit FSH and LH release hypogonadism, bone Conjugated estrogens for acute bleeding
Other treatments as indicated e.g. DDAVP for coagulation defects
UAE Surgical
Myomectomy
?D&C
Hysterectomy
2nd Generation
Cryoablation
Rollerball
Radiofrequency
Thermal Baloon
Microwave
Primary Amenorrhea
Absence of menses by age 14 with absence of SSC (e.g. breast development) or absence by age 16 with normal SSC Only 3 conditions unique to primary, other causes of amenorrhea can cause either -Vaginal agenesis -Androgen insensitivity syndrome -Turners syndrome (45, X0)
Amenorrhea, causes
Generalized pubertal delay e.g. Turner syndrome Normal puberty e.g. PCOS Abnormalities of the genital tract e.g. Ashermans syndrome
Amenorrhea, management
Hx. PE- These are probably the most important aspects in diagnosis Remember to always rule out pregnancy H & P suggests Ovarian-axis problem- TSH, prolactin, FSH, LH Hirsuitism-Testosterone, DHEAS, androstenedione and 17-OH progesterone Chronic ds.- ESR, LFTs, BUN, cr and UA CNS- MRI
Amenorrhea, management
If H and P gives no clues to diagnosisexciting Use step wise approach to diagnosis
TABLE 4 Causes of Amenorrhea Hyperprolactinemia Prolactin 100 ng per mL (100 mcg per L) Altered metabolism Liver failure Renal failure Ectopic production Bronchogenic (e.g., carcinoma) Gonadoblastoma Hypopharynx Ovarian dermoid cyst Renal cell carcinoma Teratoma Breastfeeding Breast stimulation Hypothyroidism Medications Oral contraceptive pills Antipsychotics Antidepressants Antihypertensives Histamine H2 receptor blockers Opiates, cocaine Prolactin > 100 ng per mL Empty sella syndrome Pituitary adenoma Hypergonadotropic hypogonadism Gonadal dysgenesis Turner's syndrome* Other* Postmenopausal ovarian failure Premature ovarian failure Autoimmune Chemotherapy Galactosemia Genetic 17-hydroxylase deficiency syndrome Idiopathic Mumps Pelvic radiation Hypogonadotropic hypogonadism Anorexia or bulimia nervosa Central nervous system tumor Constitutional delay of growth and puberty* Chronic illness Chronic liver disease Chronic renal insufficiency Diabetes Immunodeficiency Inflammatory bowel disease Thyroid disease Severe depression or psychosocial stressors Cranial radiation Hypogonadotropic hypogonadism (continued) Excessive exercise Excessive weight loss or malnutrition Hypothalamic or pituitary destruction Kallmann syndrome* Sheehan's syndrome Normogonadotropic Congenital Androgen insensitivity syndrome* Mllerian agenesis* Hyperandrogenic anovulation Acromegaly Androgen-secreting tumor (ovarian or adrenal) Cushing's disease Exogenous androgens Nonclassic congenital adrenal hyperplasia Polycystic ovary syndrome Thyroid disease Outflow tract obstruction Asherman's syndrome Cervical stenosis Imperforate hymen* Transverse vaginal septum* Other Pregnancy Thyroid disease
Abnormal Menstruation
Heres what you need to remember!!
Always R/O pregnancy, check pap Try to differentiate anovulatory from ovulatory bleeding Good history and physical is key( this applies to amenorrhea as well) Do a focused work up based on your H & P rather than a random set of studies In amenorrhea, where no indication of cause based on H & P, follow the stepwise algorithm for diagnosis Know the INDICATIONS for endometrial sampling
References
Slides 25 and 26 courtesy of: Master-Hunter T, Heiman D, Amenorrhea: Evaluation and Treatment. AFP April 15th 2006.