Menstrual Disorders

Menstrual Disorders
Presentation by:Oguchi A. Nwosu M.D.
Assistant Profressor
Emory Family Medicine Dept.

Menstrual Cycle
Definitions
* Menorrhagia Excessive (>80ml) uterine bleeding Prolonged (>7days) regular
* DUB Abnormal Bleeding, no obvious organic cause usually anovulatory
* Oligomenorrhea Uterine bleeding occurring at intervals between 35 days and 6 months
* Amenorrhea No menses x at least 6 months

Metrorragia, Menometrorrhagia, Polymenorrhea
Ovulatory vs Anovulatory cycles
Oligo or Amenorrhea +/- Menorrhagia
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.

DUB management
– sample endometrium
Usually followed by OCP or progestin
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
sample endometrium
Other tests as INDICATED by HX and PE
Endometrial evaluation of menorrhagia
Endometrial Biopsy
Procedure of choice (detection and cost)
Menorrhagia, medical management
* NSAID’s, 1st line, 5 days, decrease prostaglandins
* Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks, androgenic side effects
* OCP’s, esp. if contraception desired, up to 60% dec. supp. HP axis
* Continous OCP’s
* Oral continous progestins (day 5 to 26), most prescribed, antiestrogen, downregulates endormetrium
* Levonorgestrel IUD (Mirena), High satisfaction rate that approaches surgical techniques
* GnRH agonists, Inhibit FSH and LH release– hypogonadism, bone
* Conjugated estrogens for acute bleeding
* Other treatments as indicated e.g. DDAVP for coagulation defects

Menorrhagia, surgical management
Amenorrhea, physiologic causes
Primary Amenorrhea
-Vaginal agenesis
-Androgen insensitivity syndrome
-Turners syndrome
Amenorrhea, causes
Amenorrhea, management
Evaluation of Secondary Amenorrhea
Causes of Amenorrhea
Hyperprolactinemia
Antipsychotics
Antidepressants
Antihypertensives
Histamine H2 receptor blockers
Opiates, cocaine
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
Excessive exercise
Excessive weight loss or malnutrition
Hypothalamic or pituitary destruction
Kallmann syndrome*
Sheehan's syndrome
Normogonadotropic
Congenital
Androgen insensitivity syndrome*
Müllerian 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
*-Causes of primary amenorrhea only.

Abnormal Menstruation
Here’s 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

Menstrual Disorders.ppt