Barbora Kubesova Disorders of the menstrual cycle

Abnormal Vaginal Bleeding Bleeding at an unexpected time Not bleeding often enough Bleeding too often Bleeding in an unexpected amount Too little or too much Causes Hormonal Anatomical (patholo

Normal Menstrual Flow Interval days 28 day cycle women aged Duration 3-7 days Amount 30-60cc More than 80 cc excessive

Median Menstrual Index Menstrual Index Menarche/ cycle length/ flow duration Median of czech women 10 (years of age)/ 28 (days)/ 5 (days in length)

Basic Facts  Ovarian Cycle Follicular phase (varies) Luteal phase (14 days)  Endometrium cycle Menstruation Proliferation Secretory

Physiology of the menstrual cycle Coordinated hormonal control of the endometrium leading to pregnancy or regular shedding /periods/ HPO axis – hypothalamus-pituitary-ovarium peptide hormones H-P direct ovary to produce steroid hormones – control the endometrium Complex process Average age of menarché -13, menopause 52 LMP – day 1 of bleeding

Secondary amenorhoe - causes Secondary Amenorrhea  Previously normal menstrual cycles  Absence of menses for 6 months  Or for a length of time = 3 previous cycles  Multiple causes  Hormonal  Anatomical

Secondary amenorhoe - causes Secondary Amenorrhea  Common non-pathological causes  Pregnancy  Lactation  Hormonal contraception  Menopause  Always rule out pregnancy

Secondary Amenorrhea Recent Surgery Assess Anatomic Anomalies Asherman’s syndrome Destruction of endometrium Surgery, pregnancy, Infection No cramps Cervical stenosis History of cervical surgery

Secondary Amenorrhea  Hypothalamic Dysfunction FSH/LH Decreased or Normal Anorexia nervosa Excessive exercise Stress Hypothalamic lesion Drugs/medications

Secondary Amenorrhea  Pituitary Dysfunction FSH/LH Pituitary dysfunction often result of prolactin Hyperprolactinemia Hypothyroid TRH elevated prolactin Drugs (CNS) Pituitary adenoma Pituitary anatomical pathology rare Sheheen’s syndrome

Overt Hyperprolactinemia Galactorrhea Prolactin FSH/LH Multiple duct, milky nipple discharge Cause Increased prolactin Etiology Physiologic Excessive breast manipulation Pharmacologic –Phenothiazines, Antihypertensive,Antidepressants, Amphetamines Oral contraceptives Marijuana

Secondary Amenorrhea Ovarian Dysfunction FSH/LH Premature ovarian failure 40 years or less Post irradiation or chemotherapy Polycystic ovarian syndrome common cause Polycystic Appearing Ovary

Evaluation of Secondary Amenorrhea History Menstrual history Contraception Pregnancy Surgeries Medications Weight changes Chronic diseases

Evaluation of Secondary Amenorrhea Social History Drug abuse Stress Diet Sexual activity

Evaluation of Secondary Amenorrhea Family History Thyroid Type II diabetes Cancer Mother’s age at menopause

 Evaluation of Secondary Amenorrhea Physical Examination BMI Hair distribution Skin Thyroid Breasts Discharge? Abdomen Masses? Tenderness?

 Diagnostic Strategies for Secondary Amenorrhea Rule out: Pregnancy Hormonal contraception Rule out: Medications Include social substance use and complimentary therapies

 Diagnostic Strategies for SecondaryAmenorrhea Rule out: Anorexia-bulimia-athlete Determine BMI Exercise/diet patterns Rule out: Obvious anatomical causes Pelvic examination

 Diagnostic Strategies for Secondary Amenorrhea Consider: 1. TSH 2. Prolactin Determine: “Can she make estrogen now?” Normal pelvic exam? Perform progesterone challenge MPA mg 5-10 days If she bleeds polycystic ovarian syndrome

 No bleeding after progesterone challenge: Obtain FSH Elevated FSH: Ovarian failure Order TSH, ANA Normal FSH: Anatomical problems? eassess history of recent surgery

No bleeding after progesterone challenge: Low FSH Pituitary problems Hypothalamic problems Order TSH and prolactin CNS symptoms or prolactin Referral for CT or MRI Reassess anorexia, bulimia, low body fat Reassess medications or breast stimulation

 No bleeding after progesterone challenge: Low FSH and Galactorrhea Assess discharge Spontaneous milky Unilateral or bilateral No associated mass Irregular menses S/S of pituitary tumor Headaches Visual changes Symptoms of underlying condition

No bleeding after progesterone challenge: Low FSH and Galactorrhea Diagnostic Tests Serum prolactin MRI Prolactin level hogher100 TSH Other tests per underlying conditions

No bleeding after progesterone challenge: Low FSH and Galactorrhea Diagnostic Tests Serum prolactin CAT or MRI Prolactin level higher than100 TSH Other tests for underlying conditions

No bleeding after progesterone challenge: Normal FSH Consider anatomical problems History of recent surgery? Administer package of OCPs or estradiol followed by MPA No bleeding? Asherman’s syndrome Cervical stenosis

 Treatment for Hypothalamic Amenorrhea Diet, exercise, stress management Medication change Osteoporosis Assessment Treatment Consider oral contraceptive pills Counseling referral

 Treatment for Galactorrhea Precipitating factors Discontinue when identified Eliminate drugs when reasonable Treat underlying causes Hypothyroidism Bromocriptine or other dopamine agonist If normal prolactin and regular menses May manage expectantly Periodic prolactin levels

Polycystic Ovarian Syndrome Treatment Combined OCP Regulate menses Prevent endometrial hyperplasia Treat acne Cosmetic therapy Acne Hirsutism

 Abnormal Vaginal Bleeding Developmental Classifications Childhood Adolescence Reproductive Perimenopause Menopause

 Abnormal Bleeding in Adolescent Dysfunctional uterine Bleeding Irregular ovulation Diagnosis of exclusion Hormonal contraception Vulvovaginal

 Abnormal Bleeding in Perimenopause Dysfunctional uterine Bleeding Diagnosis of exclusion Benign neoplasms Endometrial polyps Degenerating submucosal fibroids Endometrial cancer Endometrial polyps

 Abnormal Bleeding in Perimenopause Exogenous hormone (HRT/ERT) Bleeding from other organs Urethra, bladder, bowel Vulvovaginal atrophy Trauma Infection

 Abnormal Bleeding in Menopause Cancer until proven otherwise Atrophic changes Bleeding from other organs Urethra Bladder Bowel

Menorrhagia Prolonged excessive bleeding at regular intervals >7 days of bleeding and/or >80 ml of uterine bleeding Regular, predictable, cyclic, cramp

 Causes of Menorrhagia Fibroids Adenomyosis Prostaglandin imbalance Non-hormonal IUD Clotting disorders Submucosal

Metrorrhagia Bleeding at irregular, but frequent intervals Amount is variable Unpredictable, often painless Irregular, irregularity

 Causes of Metrorrhagia Dysfunctional uterine bleeding Polycystic ovarian syndrome Endometrial cancer Progesterone contraceptive

Menometrorrhagia Prolonged bleeding occurring at irregular intervals both between and during menses Caused by combinations of above pathologies

Intermenstrual Bleeding Bleeding of variable amounts between menstrual periods Causes Combined hormonalcontraceptives Progesterone contraception HRT Endometritis Chlamydias

Postcoital Bleeding Bleeding following coitus or cervical manipulation Cervicitis Trichomonas Gonorrhea Chlamydia Herpes Cervical cancer Cervical polyp

Polymenorrhea Uterine bleeding occurring at regular intervals less than 21 days Causes: Short follicular phase Inadequate luteal phase Dysfunctional uterine bleeding

Oligomenorrhea Infrequent uterine bleeding with menstrual intervals greater than 35 days Causes: Menopause Adolescence OCP manipulation Hypothalamic dysfunction Chronic illness Polycstic ovary

Hypomenorrhea Unusually light flow at regular intervals Causes Oral contraceptive pills Hormonal contraception

 Gynecological Etiologies of Abnormal Bleeding Vulva/vaginal Trauma Infection Atrophy Cancer

Gynecological Etiologies of Abnormal Bleeding  Cervix Infection Polyps Cancer

Gynecological Etiologies of Abnormal Bleeding  Uterus Infection Hyperplasia Cancer Endometrial polyps Leiomyomas Adenomyosis

Gynecological Etiologies of Abnormal Bleeding  Ovaries Cancer Functional cysts

Management of Abnormal Bleeding

Dysfunctional Uterine Bleeding Hormonal contraception Cyclic progestin Treat anemia NSAIDs May need estrogen to build endometrium Refer for surgery/ablation ALWAYS rule out endometrial cancer in perimenopausal woman

Leiomyomas Classification of Leiomyomas Interstitial or intramural Within uterine wall Submucosal Protrude into uterus Subserosal Protrude through outer uterine wall Pedunculated Pedicle attached to uterus

Leiomyomas Firm, irregular, non-tender uterus May palpate firm mass Ultrasound Treat symptoms If no improvement May refer for surgery GnRH agonists prior to shrink fibroids

Adenomyosis Multiparous women Over age 30 Menorrhagia Dysmenorrhea Smooth tender uterus More pain during menses Treat symptoms Tricycle OCPS Refer for surgery

Diagnostic Strategies for Abnormal Bleeding Pelvic Start from the external genitals and work your way in for causes of abnormal bleeding

 Laboratory Strategies forAbnormal Bleeding Depend on presentation Sensitive pregnancy test Ultrasound Pap smear Cultures for GC/CT CBC, PT/PTT  Menopausal women Endometrial biopsy

Primary Dysmenorrhea  Etiology No pelvic pathology Prostaglandin induced cramping Treatment NSAIDS Contraception that inhibits ovulation Combined oral contraceptive pills Depo-Provera

 Causes of Secondary Dysmenorrhea Non-progesterone IUD Endometriosis Pelvic inflammatory disease Cervical stenosis Degenerating fibroids

PMS  What is PMS? Affects 30-40% of women of childbearing age Symptoms occur in luteal phase Symptoms of PMS Over 150 documented Relieved when menses occurs Present for at least 3 consecutive cycles

PMS  Who Gets PMS? anyone who is menstruating i.e. from puberty to menopause Most common risk factors for PMS: 30 + years old Experiencing emotional stress Difficulty maintaining stable weight History depression/anxiety Other family members experience PMS

PMS  Common PMS Symptoms Mood swings Irritability Anxiety Depression Weight gain Headaches Joint and muscle aches

PMS  Common PMS Symptoms Backaches Changes in sex drive Food cravings Water retention

PMS  Criteria for PMS Symptoms Occur in the luteal phase of cycle Increase in severity as cycle progresses Resolve with start of menses or shortlyafterwards Are present for at least 3 consecutive cycles Does NOT have to meet minimum of 5symptoms like PMDD

PMS  Causes of PMS No one exact cause has been proven Too much estrogen? Too little progesterone? Too little Vitamin B6? Too little serotonin? Too much prolactin? Change in glucose metabolism?

PMS  Treatments NSAIDs may improve dysmenorrhea Exercise and diet Calcium effective in a few trials (1500 mg/day) Serotonin uptake release inhibitors Prozac (fluoxitine) or Xanax Effective in repeated clinical trials Other antidepressants are not effective Low-dose potassium sparing diuretic Sprinolactone

PMS  Diagnosis of PMS No blood test is diagnostic PMS diary or chart for 3 months. Listen to the woman Rule out other diagnoses