Menstrual Cycle Disorders Karen Estrella H. Pediatric PGY-2 SBH Nov/2010

Objetives Introduction Normal physiology Definitions Menstrual Cycle disorders Amenorrhea Dysfunctional Uterine Bleeding Dysmenorrhea

Introduction Menarche: Duration: Median age: 12.7 yrs African-american earlier than Caucasian 2-2.5yrs after breast development Anovulatory cycles: 1st 1-2yrs of onset (55-82%) For 5 yrs (10-20%) Duration: Between 21 and 35 days (mode: 28) Lasting: 3-7days Blood lost: 30-40ml

Physiology

Physiology

Definitions Amenorrhea: Primary: absence of menarche by age 16 in the presence of normal pubertal development (Tanner 4-5) Or: lack of menses by age 14 in absence of pubertal development Secondary: absence of 3 consecutive menstrual cycles or 6 months of amenorrhea Menorrhagia: normal intervals with excessive flow Cycles more than 8days, > 80ml Metrorrhagia: irregular intervals with excessive flow Oligomenorrhea: menstruation ocurring more than every 35 days to 6 months

Menstrual Cycle Disorders

Amenorrhea

Amenorrhea Classification: With pubertal delay With normal pubertal development Genital abnormalities Hyperandrogenic anovulation

Amenorrhea 1. With pubertal delay Hypergonadotropic hypogonadism OVARIAN FAILURE Turner XY gonadal dysgenesis Autoinmmune oophoritis Exposure to chemo or RT(alkylating) 17 alpha hydroxylase deficiency Elevated FSH B A

Amenorrhea 1. With pubertal delay B. Hypogonatropic hypogonadism PITUITARY: Adenoma Prolactinoma Craniopharyngioma Hemochromatosis Hypothyroidism Breast stimulation Sx Phenothiazines, opiates (-PRL inhibitor factor) HYPOTHALAMIC: Suppresion: Stress Malnourishment Wt loss < 15% of ideal body wt Strenous exercise Body fat < 22% If prior to menarche, each yr of training delays onset by 5 months Prader-Willi Kallman Migration olfatory and GnRH neurons) Low or normal FSH

Amenorrhea 2. with normal pubertal development Pregnancy Chronic diseases Exc IBD, DM, hypothyroidism, anorexia Use of hormonal contraceptive Progestational effect Uterine synechiae (Asherman sd) Sheehan sd.

Amenorrhea 3. Genital tract abnormalities Outflow tract-related: Imperforate hymen Transverse vaginal septum Agenesis of the vagina, uterus: Mullerian Agenesis: breasts, (+) pubic and axillary hair Testicular feminization (x-linked defect androgen receptor): breast, (-) pubic axillary hair

Amenorrhea 4. Hyperandrogenic anovulation Hirsutism, acne, rarely clitoromegaly To be r/o: PCOS (polycystic ovarian syndrome) Most common Ovarian and adrenal tumor or adrenal enzyme deficiency Obesity

EVALUATION

Primary amenorrhea Presence of breasts Surgery Hormone replacement TSH PRL MRI brain testosterone Surgery Enzymatic defect Hormone replacement

Secondary amenorrhea DHEAS: > 700ng/ml Testosterone >90ug/ml Abd-pelvic MRI 17OH progesterone Asherman Hirsutism: spirinolactone 50mg po TID

Evaluation: Secondary amenorrhea Progesterone challenge test: Oral medroxyprogesterone acetate for 5-10 mg QD for 5-10 days), or IM 200mg x1. POSITIVE TEST: withdrawal bleeding 2-7 days after +uterus +estrogen stimulation: ovaries ok Estrogen-progesterone challenge test: Oral conjugated estrogen (1.25 mg) or 2 mg estradiol qd for days 1 through 21 with oral medroxyprogesterone acetate (10 mg) on days 17 through 21. Insufficient estrogen stimulation

Dysfunctional Uterine Bleeding

Dysfunctional Uterine Bleeding Prolonged # of days of bleeding or excessive bleeding Most common: anovulation the lack of progesterone secretion increases risk of endometrial hyperplasia High estrogen levels Bleeding is prolonged, irregular and sometimes profuse Adolescents Obese

DUB: Differential dx Pregnancy STD’s PID Foreign bodies Cervical neoplasia Coagulation defect: vWF

DUB: Treatment

DYSMENORRHEA

Dysmenorrhea (painful menses) Primary: Decrease of progesterone levels al end of luteal phase: lysosomal membranes are unstable::::release enzymes formation: Prostaglandins Keep increasing during luteal and menstrual phases Uterine hypercontractibility Tissue ischemia Nerve hypersensitivity (just before or 1st days of menses) Secondary: Associated with pelvic pathology: Endometriosis Miomas PID STD Genital tract obstruction (Later age, Menorrhagia, Dyspareunia, Pain with defecation, worsening with every cycle or mid-cycle, symptoms that persist after menses have finished)

Dysmenorrhea: Treatment Inhibiting prostaglandin synthesis: Ibuprofen: 400-600mg po q4-6hrs Naproxen 500mg load then 250mg po q6-8hrs Started on 1st day of bleeding Prevent ovulation and decrease endometrial growth Oral contraceptives 30-35mcg combined estrogen-progestin x4-6months Laparoscopy

SUMMARY

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