ABNORMALITY OF MENSTRUAL CYCLE

Abnormality :

Cycles

Period

Amount of bleeding

Pain associated with menses

Disorders of the Menstrual Cycle

AmenorrheaDysmenorrheaPremenstrual SyndromeAbnormal Uterine Bleeding

Abnormal Uterine Bleeding: Definitions

Menorrhagia: Heavy or prolonged uterine bleeding that occurs at regular intervals. Some sources define further as the loss of ≥ 80 mL blood per cycle or bleeding > 7 days.Hypomenorrhea: Periods with unusually light flow, often associated with hypogonadotropic hypogonadism (athletes, anorexia). Also may be associated with Asherman’s syndromeMetrorrhagia: Irregular menstrual bleeding or bleeding between periodsMenometrorrhagia: Metrorrhagia associated with > 80 mLPolymenorrhea: Frequent menstrual bleeding. Strictly, menses occur q 21 d or lessOligomenorrhea: Menses are > 35 d apart. Most commonly caused by PCOS, pregnancy, and anovulation

Abnormal Uterine Bleeding: Differential DiagnosisStructural

Cervical or vaginal lacerationUterine or cervical polypUterine leiomyomaAdenomyosisCervical stenosis/Asherman’s (hypomenorrhea)

HormonalAnovulatory bleedingHypogonadotropic hypogonadismPregnancyHormonal Contraception (i.e. OCPs, Depo-Provera)Thyroid disordersHyperprolactinemia

MalignancyUterine or Cervical cancerEndometrial hyperplasia (potentially pre-malignant)

Bleeding disordersvon Willebrand’s Disease, Hemophilia/Factor deficiencies, platelet disorders

How to approach the diagnosis ?

Anamnesis :- Chief complain- History of menstrual cycles- Family history of abnormality of menstruation- Developmental disorders- History of other disease- History of medication including contraception- Psychological disorders

- Physical examination- Laboratory diagnostic

- USG- Laparoscopy- X-Ray- CT Scan- Colposcopy- MRI

Therapy : - Depend on etiology- Induction of menstruation

AMENORHEA

Definition

1. Do not reach menarche, without secondary sexual development until 13 years old

2. Until 15 years old with secondary sexual development, but not reach menarche

3. absence of periods for a length of time equivalent to a total of at least three of the previous cycle intervals or 6 months of amenorrhea

Classification (classical)

Primary amenorhea : Not have reach menarche at all

Secondary amenorhea : Had a menstruation before than stop.a. Physiologically : Puerpuerium

Breast feedingDuring pregnancyMenopause

b. Pathologically : Other causes.Amenorhea could be followed by

galactorhea andhirsutism.

Causes of AmenorrheaDisorders of sexual differentiation

Distal genital tract obstructionGonadal dysgenesisAmbiguity of external genitalia

Other peripheral causesPregnancyGestational trophoblastic disease

Aseherman’s syndrome

Causes of Amenorrhea

Chronic anovulation or ovarian failureDue to CNS-hypothalamic-pituitary dysfunctionDue to inappropriate feedback (PCOS)Due to thyroid and adrenal disordesPersumtive ovarian failure

DISMENORHEA

DefinitionPain that feel just before or on

menstruation

Classification : Primary

dismenorhea/functional/idhiopatic : pain that have no pathological causes

Secondary dismenorheaCaused by factor that could be found

Etiology :Prostaglandin theory F2-a

Prostaglandin elevated the end of menstrual cycles caused contraction of uterus ischemia pain.

Secondary dismenorheaCould be caused by :- Pelvic infection- Endometriosis- Myoma- IUD- Endometrial polyp

Treatment : SymptomaticEndocrinologyOperativePsychology

Symptomatic treatment : - Analgesic- Sedative- Antispasmodic- Diuretic- Light exercises- Bed rust- Oral contraceptive- Tocolytic- Panasacral neurectomy

DISFUNGTIONAL UTERINE BLEEDING

Definition

Is an abnormal bleeding from uterus that came only by hormonal disturbance without organic abnormalities.

Happen in teenagers, reproductive period and premenopause period.

Clasification :1. DUB in anovulation cycles

Corpus luteum do not developed, level of estrogen is high, progesteron level is low.

2. DUB in ovulation cycles- midcycles bleeding- Bleeding cause by disturbance in

endometrial release- Spotting premenstruation and

postmenstruation.

3. DUB in persistent follicles- often found in reproductive line- Endometrial hyperplasia : -Simplex

- Cystic- Atypical

How to reach diagnosis

1. Anamnesis, gynecological examination2. Anovulation diagnosis

Basal temperature : monophasicProgestin level : lowGonadotropin level : LH lowHyperfunction of adrenal : high

testosteronHypothyroid : high TSHEndometrial Biopsy : atrophy,

proliferateMittelschmeric : absentMenstrual cycles : irregular.

Treatment Hormonal therapy combination estrogen and progesteron

OTHER DISTURBANCE

I. Pseudoamenorhea / Kriptomenorhea

Definition

There is menstruation, but the blood could not expelled became blockade on cervix, vagina, hymen.

Classification- Congenital- Acquisita : a. Infection (GO,

diphtheria)b. Abnormal deliveryc. Senility

Diagnosis : Molimina menstrualia Hematokolpos Hematometra

Hematosalphing

Treatment :Incision/excision of blockade hymen

II. Menstrual Praecock

DefinitionBleeding in below 10 years child, accompanied by secondary sexual development.

Classification :a. Puberty praecock Gonadotropin is formed, could get pregnant Idiopathic Central puberty praecock Albright syndrome Neoplasm that produce gonadotropin

b. Pseudopuberty pracock

There is no gonadotropin, and no ovulation :

Granulosa cell tumors/techa cell tumor Disturbance on suprarenal glands Gonad therapy

IV. Polymenorhea

Short period, less than 21 days.

A. If the cycles is short, but regular :

- short of proliferation phase

- short of secretion phase

- both of them

B. Cycles that previously normal but become, shorter

Happen in :- Climacterium- Puberty- TBC

Therapy :Estrogen on combination betweenEstrogen and progesterone

Oligomenorhea

Menstruation rare, long cycles more that 2 months

Caused by :- Prolonged follicular phase- Prolonged luteal phase- Both of themAlways think about pregnancy.

Menorhagia

Expelled blood in large amount in regular menstrual cycles

Caused by :

Hypoplasia uteri Asthenia During or after diseases Myoma Hypertension Decompensatio cordis Infection Hemophilia

MetrorhagiaIrregular bleeding do not associated with menstrual cycles.

I. Caused by pregnancy- Abortion- Ectopic pregnancy

II. Not caused by pregnancyUsually hormonal or organic.