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Menstrual Disorders. 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 DUB Abnormal Bleeding, no obvious organic cause usually anovulatory

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Menstrual disorders

Menstrual Disorders

Oguchi A. Nwosu M.D.

Assistant Profressor

Emory Family Medicine Dept.

6/28/07



Definitions
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
Ovulatory vs Anovulatory cycles

  • Anovulatory

    Oligo or Amenorrhea +/- Menorrhagia

  • Ovulatory

    Regular menstrual cycles (plus premenstrual symptoms such as dysmenorrhea and mastalgia


Menstrual disorders
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
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
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
DUB management cramps

  • HCG, CBC, TSH

  • ? Coagulation workup

  • Ensure pap smear UTD if appropriate

  • >35 or Ca risk factors, tamoxifen use

    – sample endometrium


Dub management1
DUB management cramps

  • 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
Menorrhagia cramps

-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


40 year old with menorrhagia x 12 months

5ft’5”, 155Ibs, husband ‘castrated’ cramps

Had normal 28 day cycles lasting 5 days

Last 1 year or so very heavy periods with clots and occ. ‘flooding’ in the first 3 days with need to use >8pads/day fully soaked, spots for up to 1 week after this.

Dysmenorrhea, severe, aching pain lower legs

Normal recent pap

40 year old with menorrhagia x 12 months

  • Picture of middle aged woman


Menorrhagia management
Menorrhagia, crampsManagement

  • History

  • Physical exam-anemia, obesity, androgen excess e.g. hirsuitism, acne, ecchymosis/purpura, thyroid, galactorrhea, liver/spleen, Pelvic- Uterine, cervical and adnexal


Menorrhagia management1
Menorrhagia, crampsmanagement

  • 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



Menorrhagia medical management
Menorrhagia, crampsmedical 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
Menorrhagia, crampssurgical management


Menorrhagia surgical management1
Menorrhagia, crampsSurgical Management


Menorrhagia management summary
Menorrhagia, crampsmanagement summary

  • Tailor treatment to individual patient.

  • Consider patients age, coexisting medical diseases, FH, desire for fertility, cost of rx and adverse effects

  • Surgical management reserved for organic causes (e.g fibroids) or when medical management fails to alleviate symptoms


Amenorrhea physiologic causes
Amenorrhea, crampsphysiologic causes

  • Male gender

  • Prepubertal female

  • Pregnant female

  • Postmenopausal female


Primary amenorrhea
Primary Amenorrhea cramps

  • 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
Amenorrhea, crampscauses

  • Generalized pubertal delay e.g. Turner syndrome

  • Normal puberty e.g. PCOS

  • Abnormalities of the genital tract e.g. Ashermans syndrome


Amenorrhea management
Amenorrhea, crampsmanagement

  • 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, LFT’s, BUN, cr and UA

  • CNS- MRI


Amenorrhea management1
Amenorrhea, crampsmanagement

  • If H and P gives no clues to diagnosis-exciting

    Use step wise approach to diagnosis



Abnormal menstruation here s what you need to remember
Abnormal Menstruation crampsHere’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
References cramps

  • Slides 25 and 26 courtesy of:

    Master-Hunter T, Heiman D, Amenorrhea: Evaluation and Treatment. AFP April 15th 2006.