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Menses

Dr. Said Sarahneh


Faculty of medicine
Al Quds University
September, 2012
Normal Menstrual Flow
Interval : 21-35 days
Duration : 3-7 days
Amount 30-60 CC , more than 80cc
excessive
Normal Menstrual Physiology
Hypotalamus GnRH
Pituitary gland gonadotropins (FSH, LH).
Ovarian follicle Estrogen stimulate endometrium
(Proliferative phase)
Corpus Luteum progesterone (secretory phase).
Endometruim CL degenerate after 14 days
decreased progesterone level Endometrial spiral
arteriolar spasm break down shedding.
Outflow tract.

Axis of Menses Control
Hypothalamus


GnRH

Pituitary


FSH, LH

Ovary


Estrogen, Progesterone

Endometrium

Outflow tract
Normal Development of
Secondary sexual Characteristics
8-9 years Slowest growth rate
9-10 years Thelarche: Breast budding
10-11 years Adrenarch: Pubic and axillary hair
11-12 years Maximal growth rate
12-13 years Menarche: Onset of menses
13-14 years Adult pubic hair
14-15 years Ovulation
Amenorrhea
Amenorrhea = absence of menstruation
Primary amenorrhea = failure of menarche to occur
before 16 years of age or within 4 years of thelarche
No menses by age 14 years, and absence of secondary sex
characteristics.
No menses by age 16 years, with presence of secondary
sex characteristics.
Secondary Amenorrhea = cessation of menses for at
least 6 months in a premenopausal woman
No menses for 3 months, if previous menses were regular
No menses for 6 months, if previous menses were irregular
Causes of amenorrhea
1. Pregnancy
2. Genital tract abnormalities
Congenital:
Imperforated hymen
Congenital absence of vagina or cervix
Absence of the mullerian duct
Acquired :
Cervical obstruction/stenosis
Intrauterine adhesions
Causes of amenorrhea
3. Ovarian failure
Gonadal dysgenesis (45X,46XX, 46XY)
Premature ovarian failure (postpubertal)
4. Pituitary disorders
Hyperprolactinemia
Tumors
Sheehan syndrome
5. Hypothalamic disorders
Stress (weight loss, exercise, emotional)
Congenital (Kallmann syndorme)
6. Polycystic ovary syndrome



Hypothalamic Disorders
Low FSH, LH
Congenital syndromes
Systemic stresses
Significant weight loss
Anorexia
Bulimia
Excessive exercise
Severe emotional distress
Pituitary Disorders

Elevated serum prolactin level.
r/o phamacologic and physiologic causes of
hyperprolactinemia.
Tumor.
Pituitary adenoma (micro or macro)
Low serum prolactin level
Sheehan syndrome
Head trauma
Destructive neoplastic processes
Pituitary Gland
Sheehan syndrome (pp Necrosis of hypertrophied
pituitary gland) Hypopituitarsim decreased
FSH, LH.
Negative feed back inhibition pituitary from
Exogenous hormone (OCP).



Ovary
Testicular Feminization syndrome (ovarian agenasis)
Turners syndrome (ovarian dysgenesis)
Premature ovarian failure due to infection (mumps),
chemotherapy, radiotherapy, trauma, PCOD.
Uterus and Vagina
Uterine agenesis.
Testicular feminization syndrome.
Mullarian agenesis.
Roktanski miller syndrome.
Ashermans syndrome following D&C.
Imperforated hymen.
Transverse vaginal septum.
Abnormal Uterine Bleeding
Pregnancy
Pelvic infection
Anovulation
Leiomyoma/polyps
Adnexal pathology
Endometrial hyperplasia
Endometrial carcinoma


Investigations
FSH level , LH level :
If FSH, LH ovarian cause.
If FSH, LH pituitary or hypothalamic.
HCG to R/O pregnancy.
U/S for ovary, uterine abnormality.
Challenge Tests.
Progesterone challenge test
150 mg parenteral progesterone / or
medroxyprogesterone acetate 10 mg for 5 days.
Positive withdrawal response anovulatory.
Negative withdrawal response:
obstruction (e.g., cervical stenosis), or intrauterine
adhesions (e.g., Ashermans syndrome).
Inadequate estrogen.

Combined estrogen and progestin
Challenge test
Oral conjugated estrogens 1.25 mg for 21 days
combined with oral medroxyprogesterone acetate 10
mg for the last 5 days.
Positive response : 2-7 days inadequate estrogen
production.
The ovaries do not contain adequate function follicles.
Folicles are present but there is inadequate pituitary
gonadotrpic stimulation.
Negative : Obstruction or defect in the endometrium

Terminology of Abnormal
Bleeding
Oligomenorrhea = bleeding at intervals 40 days
that usually is irregular.
Polymenorrhea = bleeding at intervals 22 days
that may be regular or irregular.
Menorrhagia = bleeding that is excessive in both
amount and duration at regular intervals.
Metrorrhagia = bleeding of usually normal amount
but at irregular intervals.

Terminology of Abnormal Bleeding
Menometrorrhagia = bleeding that is excessive in
amount, is prolonged in duration, and may occur at
regular or irregular intervals.
Hypomenorrhea = regular uterine bleeding in
decreased amount.
Intermenstrual bleeding = bleeding that occurs
between what is otherwise regular menstrual
bleeding.
Bleeding in the Reproductive
Years
DUB dysfunctional uterine bleeding Only use if
no other organic cause of bleeding is found.
Organic Pathology:
Pregnancy (intrauterine or ectopic)
Neoplasia
Genital tract Cx, endometrial, ovarian, tube
etc.
Othe CNS, adrenal, thyroid.


Organic Pathology Causing
Bleeding in Reproductive Yrs
Polyp Cx endometrial
Leiomyoma
Adenomyosis
Infection cervicitis, endometritis.
Endomcrine dysfunction
Pituitary/hypothalamus
Adrenal
Thyroid


Organic Pathology Causing
Bleeding in Reproductive Yrs
Iatrogenic
IUD
Drug use
Hormones
Nonhormonal effects dopamine metab
(phenothiazines, TCAs, reserpine,
alphamethyldopa.




Oligomenorrhea
Regular frequency.
Normal amount and duration.
Cycle > 35 days.
Causes
Anovulation is the most common cause.
Resistant ovary syndrome.
PCOD, Hyperprolactinemia.


Treatment
Oligmenorrhea
Combined OCP
Progesterone
Estrogen alone > 3 months
Endometrial hyperplasia
risk of endometrial CA.

Polymenorrhea
Regular frequency
Normal amount and duration
Cycle < 21days

Give OCP return to normal
Exclude polyps or fibroid

Menorrhagia
Regular frequency
amount and duration
> 180 cc /day
Cycle 21-35 days
Hx of clots with menses

Etiology
Idiopathic 90%
Organic causes 10%
Fibroid
Vonwillibrand dz.
Pelvic infection
Trauma
Most common indications of hystrectomy.
Treatment
Medical:
Anti PG Mefanemic (NSAIDs)
Compound OCP
Hexacaprone (Anti fibrinolytic)
Surgical:
Hysterectomy
Endometrial ablation
Thermal
Laser
Balloon

Dysmenorrhia
Painful menstrual periods

50% Of menstruating woman

10% Sever symptoms
Classification
Primary:
- Occurs in young woman within 2y
of menarche
- Familial predisposition
- Excessive myometrial contractions
due to progesterone withdrawal
resulting in uterine ischemia uterine
attack
- No pelvic pathology
MANAGEMENT : NSAIDs or OC.
Secondary :
- after ovulatory cycle
- Associated with pelvic pathology
- Causes :
1- Endometriosis
2- Cervical stenosis
3- Pelvic congestion syndrome
4- Ovarian cysts
5- Uterine leiomyomas
6- PID
MANAGEMENT DEPEND ON DIAGNOSIS
Abnormal Uterine Bleeding
Vagina & vulva : atrophy, trauma, infec.,
malignancy
Cerivx : Erosion, inf., polyps, malignancy.
Uterus : 1
st
trimester bleeding, leiomyomas,
adenomyosis, hyperplasia, malignancy
Oviducts : salpingitis ectopic pregnancy
Ovaries : estrogen-producing tumors, CA
Clinical Work Up
-hCG
-evaluation of the cycle :
1- ovulatory cycles
2- unovulatory cycles

Ovulatory cycle
Regular & predictable
Basal body temp. (BBT) shows med
cycle elevation.
Serum progesterone > 500 ng/dl.
Endometrial biopsy shows secretory
changes
Unovulatory cycle
Not predictable & irregular.
Monophasic BBT.
DUB : in the extremes of reproductive
years.


Polycystic ovary disease
(stein leventhal syndrome)
Def. endocrinological and gynecological dz.
Characterized by:
Excessive androgen production
Prolonged anovulation
Multiple fluid filled cystic lesions of ovary
Epidemiology:
Up to 22% of women
So some says its a variant of normal.
Pathogenesis
Exactly unknown
Defect in ovarian maturation

Clinical Presentation
Symptoms :
An ovulation oligomenorrhea
Infertility
Hirsutism
Dysfunctional uterine bleeding (DUB)
Laboratory :
androgen
LH / FSH ration 3
15 % of high prolactin level

Ultrasound :
- necklace sign of ovary :
small follicular cysts of peripheral
distribution
Premenstrual syndrome
90% of women has some degree of PS
Symptoms present in the 2
nd
half of
menstrual cycle.
No symptoms at 1
st
week.
Symptoms are recurrent at least 3
consecutive cycles.
Symptoms are severe sometimes and
require treatment.
Management Of PS
Nutrition.
Life style.
Medication :
-selective serotonin re uptake.
inhibitors (SSRIs) = prozac.
-diuretics = spironolactone.
-NSAIDs.
-promocriptine.