ALL ABOUT MENTRUATION ABNORMALITIES

1. Menarche to
Menopause
DR.DIVYA JAIN
INDORE

3. Menstruation
 Shedding the uterine lining
(endometrium) if pregnancy does not
occur.
 Necessary (in the absence of
hormonal regulation) to insure the
endometrium does not become
hyperplastic.

4. Normal Menstrual
Cycles
 Mature, ovulatory women
– 28-29 day average
– 21-36 day range
– 2-7 days duration
– 20-80 cc of blood loss per month

5. Cycle Variation
 Women in their middle reproductive
years have the most predictable cycles
 More pronounced cycle to cycle
variability in the 5-7 years after
menarche and 6-8 years before
menopause

6. Cycle Variation (cont.)
 Adolescents
– Majority range 21-48 days
– Usually anovulatory
– Mean time from menarche until half the cycles
are ovulatory depends upon the age of
menarche
– 12 yrs 1yrs till half cycles are ovulatory
– 12-13 3yrs
– >13 4.5 yrs

7. Cycle Variation (cont.)
 Perimenopause
– Cycles initially shorten
– Ultimately (apparently) lengthen, as an
entire cycle will be skipped
 Average age of menopause is 51
– Cessation of menses for one year

9. Abnormal Uterine
Bleeding
 Menorrhagia
 Oligomenorrhea
 Metrorhhagia
 Polymenorhhea
 Menometrorhhagia
 Oligomenorrhea
 Contact bleeding

10. Terminology
 Amenorrhea—lack of menstrual bleeding
– Primary—no menses by age 16
– Secondary—absence of 3 or more expected
menstrual cycles
 Break-through bleeding (BTB) unexpected
bleeding usually occurring while a woman is
on exogenous hormonal medication (eg
OCPs, patch, or ring)

11. Terminology (cont.)
 Menorrhagia—heavy menstrual bleeding.
Prolonged or excessive menstrual blood
loss with regular cycles
 Metrorrhagia—irregular, frequent bleeding
 Menometrorrhagia—irregular menses with
prolonged or excessive blood loss
 Midcycle bleeding—light menstrual
bleeding occurring in ovulatory women at
the midcycle estradiol trough

12. Terminology (cont.)
 Oligomenorrhea-- menstrual
bleeding/menses occurring less frequently
than 36 days apart
 Polymenorrhea—frequent menstrual
bleeding/menses occurring more frequently
than 21 days apart
 Contact bleeding/post-coital bleeding
 Dysmenorrhea- painful menstrual bleeding

13. Impact on Health
 75% of women experience physical changes
associated with menses
 PMS (Premenstrual syndrome)
 PMDD (Premenstrual dysphoric disorder)
 Direct and indirect health care costs
– Visits to ED, clinic, or office
– Time lost from work

14. PMS
 Psychoneuroendocrine d/o with
biological, social and psychological
impacts
 Up to 75% of women experience some
level of recurrent sx
 Up to 5% may experience severe sx
and distress

15. Common PMS
Symptoms
 Headache
 Breast pain
 Bloating
 Irritability
 Fatigue
 Crying
 Abd pain
 Clumsiness
 Sleep alteration
 Labile mood
 Social withdrawal
 Libido change
 Appetite change

16. Requisite Symptoms
for PMDD Diagnosis
 Depressed mood
 Anxiety/tension
 Mood swings
 Irritability
 Decreased interest
 Concentration
difficulties
 Fatigue
 Appetite changes/food
cravings
 Insomnia/hypersomnia
 Feeling out of control
 Physical symptoms
 5/11 symptoms
needed for
diagnosis and
 Sx disrupt daily
functioning

17. PMS/PMDD Tx
 Limit caffeine, tobacco, alcohol and
sodium
 Frequent high-complex carb meals
 CBT, stress management, aerobic
exercise

18. Dysmenorrhea
 Painful menstruation- when pain
prevents normal activity and requires
medication
 Pain starts when bleeding starts
 Prostaglandin activity
 Emotional/psychological factors

19. Dysmenorrhea tx
 NSAIDs, starting a day before period
– Ibuprofen, naproxen
 Anti-prostaglandins much less
effective after pain is established
 Continuous heat to abd
 OCPs for 6-12 months have lasting
benefit

20. Ddx of Abnormal
Uterine Bleeding
 Blood Dyscrasias
 Anatomic causes of bleeding,
including pregnancy
 Anovulation
 Malignancy
 Non-uterine causes of bleeding

21. AUB work-up
 Hx
 PE with cytology
 Pelvic ultrasound
 Endometrial biopsy
 Hysteroscopy
 D & C

24. Leiomyomas (Fibroids)
 Benign neoplasms arising from uterine wall
smooth muscle cells
 20-25% of reproductive age women
 Can be small to quite large, single or
multiple. Surrounded by pseudocapsule.
 Often asx, but can cause metrorrhagia,
menorrhagia, dysmenorrhea and infertility
 Cause unknown, but hormone responsive

25. Fibroid Tx
 Depends on sx, age, parity,
reproductive plans, general health,
and size/location of leiomyomas
 GnRH agonists- to shrink fibroid
 OCPs control bleeding but do not treat
the fibroid
 Progestin-releasing IUD for multiple
small leiomyomata

26. Fibroid Tx - Surgical
 Myomectomy- preserves fertility, high risk
for fibroid recurrence
 Hysterectomy- eliminates sx and chance of
recurrence. Also eliminates uterus.
 Uterine fibroid embolization (UFE)
– Embolic occlusion of uterine arteries
– As effective as above, few recurrences, few
major complications

27. Anovulation
 Patient History—very important to
diagnosis
– Ovulatory cycles—consistent number of
days from beginning of one cycle to the
next, breast tenderness, and
dysmenorrhea usually present
– Anovulatory cycles—variation in
number of days per cycle, no breast
tenderness, and dysmenorrhea is not
consistent from one cycle to the next

28. DUB
 “Dysfunctional uterine bleeding”
 Abnormal uterine bleeding with
pathologic causes ruled out
 So..you’ve done all that stuff, and it’s
all okay
 Usually tx with hormones (ie OCPs) to
control bleeding

29. Non-uterine causes
 Genital neoplasms of the vulva or vagina
– To avoid missing vaginal lesions, stainless steel
speculum blades should be rotated on removal
to fully evaluate the vaginal mucosa
– Better: use plastic speculum with good light
source
 Genital trauma/foreign objects
 Rectal bleeding or urinary tract source

30. Evaluation
 History
– Menstrual pattern (duration, changes in
quality, color of menses)
– Dysmenorrhea, mittleschmerz, breast
changes
– Post-coital spotting
– Dietary practices, change in weight,
exercise, stress
– Evidence of systemic disease

31. Evaluation (cont.)
 Physical Exam
– Vital signs, height, weight, body phenotype, BMI
– Skin, hair (acne, hirsutism pattern)
– Fat distribution, striae
– Thyroid
– Breast exam to check for galactorrhea
– Complete pelvic exam
– Tanner stage for teens

32. Evaluation--testing
 All patients:
– Pregnancy test
– CBC with platelets
– Recent Pap
 Over 35 yrs:
– Endometrial sample
 Documented drop in
hgb <10
– PT, PTT
– Bleeding time
 As indicated:
– TSH
– Prolactin
– Testosterone
– LH/FSH
– 17-OH progesterone
– Overnight
dexamethasone
suppression test or 24
hr urinary free cortisol
– Hysteroscopy or
ultrasound

33. Acute Bleeding: Control
 Oral progestins:
– Micronized Progesterone 200 mg (Prometrium)
or Medroxyprogesterone 10 mg (Provera) or
Norethindrone 5 mg (Aygestin)
– 1 po q4 hrs or until bleeding stops, then
– 1 qid x 4 days
– 1 tid x 3 days
– 1 bid x 2 weeks, then
– Cycle monthly with progestin or low dose oral
contraceptive

34. AUB Long Term Control
 Cycle with low dose OCP, patch, or vaginal
ring
 Cycle with a progestin, eg Prometrium
 Use of progestin-containing IUD (Mirena)
 Choice depends upon:
– Contraceptive need
– Smoking status
– Medical history
– Patient preference

35. Endometriosis
 Abnormal growth of endometrial tissue
in locations other than the uterine
lining
 3-10% of women of reproductive age
 30% of infertile women

38. Tx
 Analgesics (ibu)
 Hormones
– OCPs or progestins
– Danazol- prevents gonadotropin release, inhibits
midcyle LH and GSH. Androgenic side fx
– GnRH agonists (Lupron)- with continuous admin,
suppresses gonadotropin secretion
 Assisted reproduction when desired

39. Amenorrhea
 Absence of menses
 Primary amenorrhea- no menses by age 16
with otherwise nl development
 Secondary amenorrhea- absence of
menses for 3 or more cycles or 6 months in
a previously menstruating female
– MC cause??
– 3% in genl population
– 100% under extreme stress
 Examples?

40. Tx
 Desiring pregnancy?
– Ovulation induction
 Not desiring pregnancy?
– If hypoestrogenic, combo tx with estrogen and
progesterone to maintain bone density and
prevent genital atrophy
– Normal progestin challenge: needs occasional
progestin to prevent endometrial hyperplasia and
cancer
– OCPs work well for either, and can decrease
hirsutism
– Calcium, too!

41. THANKTHANK
YOUYOU