Menstrual DisordersMenstrual Disorders

DR:HUSSEIN H AKLDR:HUSSEIN H AKLO&G SPECIALISTO&G SPECIALISTMOH MALAYSIAMOH MALAYSIA

18 nov.201218 nov.2012

Menstrual CycleMenstrual Cycle

DefinitionsDefinitions

Menorrhagia Menorrhagia Excessive (>80ml) uterine bleeding Excessive (>80ml) uterine bleeding Prolonged (>7days) regularProlonged (>7days) regular

DUB DUB Abnormal Bleeding, no obvious organic cause Abnormal Bleeding, no obvious organic cause usually anovulatoryusually anovulatory

Oligomenorrhea Oligomenorrhea Uterine bleeding occurring at Uterine bleeding occurring at intervals between 35 days and 6 monthsintervals between 35 days and 6 months

Amenorrhea Amenorrhea No menses x at least 6 monthsNo menses x at least 6 months

Metrorragia, Menometrorrhagia, Metrorragia, Menometrorrhagia, PolymenorrheaPolymenorrhea

Ovulatory vs Anovulatory cyclesOvulatory vs Anovulatory cycles

Anovulatory Anovulatory Oligo or Amenorrhea +/- MenorrhagiaOligo or Amenorrhea +/- Menorrhagia

Ovulatory Ovulatory Regular menstrual cycles (plus premenstrual symptoms such as Regular menstrual cycles (plus premenstrual symptoms such as

dysmenorrhea and mastalgiadysmenorrhea and mastalgia

DUBDUB

-Defn: Excessively heavy, prolonged or -Defn: Excessively heavy, prolonged or frequent bleeding of uterine origin that is frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic not due to pregnancy, pelvic or systemic diseasedisease

-Diagnosis of exclusion-Diagnosis of exclusion

- Anovulatory- Anovulatory

-Usually extremes of reproductive life and in -Usually extremes of reproductive life and in pts with PCOSpts with PCOS

DUB pathophysiologyDUB pathophysiology

Disturbance in the HPO axis thus changes Disturbance in the HPO axis thus changes in length of menstrual cyclein length of menstrual cycle

No progesterone withdrawal from an No progesterone withdrawal from an estrogen-primed endometriumestrogen-primed endometrium

Endometrium builds up with erratic Endometrium builds up with erratic bleeding as it breaks down.bleeding as it breaks down.

16year old with daily heavy vaginal 16year old with daily heavy vaginal bleeding with clots, no crampsbleeding with clots, no cramps

5ft 7in, 105ibs, normal 5ft 7in, 105ibs, normal sec. sex xristics, pelvic sec. sex xristics, pelvic normalnormal

Menarche 14, 2 periods Menarche 14, 2 periods last year, heavy lasts 2 last year, heavy lasts 2 weeks, virginal.weeks, virginal.

I month hx of daily heavy I month hx of daily heavy vag bleeding with clots, 8 vag bleeding with clots, 8 to 10 pads x dayto 10 pads x day

No associated symptomsNo associated symptoms

Picture of teenagerPicture of teenager

DUB managementDUB management

HCG, CBC, TSHHCG, CBC, TSH

? Coagulation workup? Coagulation workup

Ensure pap smear UTD if appropriateEnsure pap smear UTD if appropriate

>35 or Ca risk factors, tamoxifen use>35 or Ca risk factors, tamoxifen use

– – sample endometriumsample endometrium

DUB managementDUB management

I/V or I/M conjugated estrogen therapy I/V or I/M conjugated estrogen therapy acute DUB--How ?!!!. acute DUB--How ?!!!.

Usually followed by OCP or progestinUsually followed by OCP or progestin

Cyclic progestins for 10 to 12 days each Cyclic progestins for 10 to 12 days each cycle, consider mirena IUDcycle, consider mirena IUD

OCP OCP

D and C – old school, no longer D and C – old school, no longer recommended. recommended.

MenorrhagiaMenorrhagia

-Heavy vaginal bleeding that is not DUB-Heavy vaginal bleeding that is not DUB-Usually secondary to distortion of uterine -Usually secondary to distortion of uterine

cavity- heavy with or without prolongation cavity- heavy with or without prolongation (anatomic).(anatomic).

Uterus unable to contract down on open Uterus unable to contract down on open venous sinuses in the zona basalisvenous sinuses in the zona basalis

-Other causes organic, endocrinologic, -Other causes organic, endocrinologic, hemostatic and iatrogenichemostatic and iatrogenic

-Usually ovulatory-Usually ovulatory

40 year old with menorrhagia x 12 40 year old with menorrhagia x 12 monthsmonths

5ft’5”, 155Ibs, husband 5ft’5”, 155Ibs, husband ‘castrated’‘castrated’Had normal 28 day cycles Had normal 28 day cycles lasting 5 dayslasting 5 daysLast 1 year or so very Last 1 year or so very heavy periods with clots heavy periods with clots and occ. ‘flooding’ in the and occ. ‘flooding’ in the first 3 days with need to first 3 days with need to use >8pads/day fully use >8pads/day fully soaked, spots for up to 1 soaked, spots for up to 1 week after this.week after this.Dysmenorrhea, severe, Dysmenorrhea, severe, aching pain lower legsaching pain lower legsNormal recent papNormal recent pap

Picture of middle Picture of middle aged womanaged woman

Menorrhagia, Menorrhagia, ManagementManagement

HistoryHistory

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

Menorrhagia, Menorrhagia, managementmanagement

HCG, CBC, TSHHCG, CBC, TSH

? Coagulation workup? Coagulation workup

Ensure pap smear UTD if appropriateEnsure pap smear UTD if appropriate

>35 or Ca risk factors, tamoxifen use>35 or Ca risk factors, tamoxifen use

sample endometriumsample endometrium

Other tests as INDICATED by HX and PEOther tests as INDICATED by HX and PE

Endometrial evaluation of Endometrial evaluation of menorrhagiamenorrhagia

Endometrial Endometrial BiopsyBiopsy

Sensitivity -91%Sensitivity -91%

False positive rate -False positive rate -2%2%

Office procedure, well tolerated, Office procedure, well tolerated, anesthesia and cervical dilation usually not anesthesia and cervical dilation usually not requiredrequired

Transvaginal Transvaginal Ultrasound Ultrasound (TVS)(TVS)

Sensitivity -88%Sensitivity -88% Good visualization of fibroids; may fail to Good visualization of fibroids; may fail to identify other intracavitary abnormalitiesidentify other intracavitary abnormalities

like polypslike polyps

Saline Infusion Saline Infusion Sonohysterosc-Sonohysterosc-

Opy (SIS)Opy (SIS)

Sensitvity -97%Sensitvity -97%

NPV -94%NPV -94%

Procedure of choice (detection and cost).Procedure of choice (detection and cost).

Sterile isotonic fluid is instilled into the Sterile isotonic fluid is instilled into the uterus under continuous visualization of uterus under continuous visualization of

endometrium with TVSendometrium with TVS

HysteroscopyHysteroscopy Sensitivity -100%Sensitivity -100% Highest cost. Better in pre-menopausal Highest cost. Better in pre-menopausal women. Does not reduce hysterectomy women. Does not reduce hysterectomy rate even without intracavitary path. Used rate even without intracavitary path. Used as gold standard for other proceduresas gold standard for other procedures

Menorrhagia, Menorrhagia, medical managementmedical management

NSAID’s, NSAID’s, 11stst line, 5 days, decrease prostaglandins line, 5 days, decrease prostaglandins

Danazol, Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks, Androgen and prog. competitor , amenorrhea in 4-6 weeks, androgenic side effectsandrogenic side effects

OCP’s, OCP’s, esp. if contraception desired, up to 60% dec. supp. HP axisesp. if contraception desired, up to 60% dec. supp. HP axis

Continous OCP’sContinous OCP’sOral continous progestins (day 5 to 26), Oral continous progestins (day 5 to 26), most most prescribed, antiestrogen, downregulates endormetriumprescribed, antiestrogen, downregulates endormetrium

Levonorgestrel IUD (Mirena), Levonorgestrel IUD (Mirena), High satisfaction rate that High satisfaction rate that approaches surgical techniquesapproaches surgical techniques

GnRH agonists, GnRH agonists, Inhibit FSH and LH release– hypogonadism, boneInhibit FSH and LH release– hypogonadism, bone

Conjugated estrogens for acute bleedingConjugated estrogens for acute bleedingOther treatments as indicated e.g. DDAVP for coagulation defectsOther treatments as indicated e.g. DDAVP for coagulation defects

Menorrhagia, Menorrhagia, surgical managementsurgical management

UAE

? D & CHysterect-

omy

Myomectomy

Ablation

Surgical

Menorrhagia, Menorrhagia, Surgical ManagementSurgical Management

Ablation

2nd Generation1st Generation

Resection (TCRE)

Cryoablation Rollerball RadiofrequencyThermalBaloon

Microwave

Menorrhagia, Menorrhagia, management summarymanagement summary

Tailor treatment to individual patient.Tailor treatment to individual patient.

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

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

Amenorrhea, Amenorrhea, physiologic causesphysiologic causes

Lactational Lactational

Prepubertal femalePrepubertal female

Pregnant femalePregnant female

Postmenopausal femalePostmenopausal female

Primary AmenorrheaPrimary Amenorrhea

Absence of menses by age 14 with Absence of menses by age 14 with absence of SSC (e.g. breast development) absence of SSC (e.g. breast development) or absence by age 16 with normal SSCor absence by age 16 with normal SSC

Only 3 conditions unique to primary, other Only 3 conditions unique to primary, other causes of amenorrhea can cause eithercauses of amenorrhea can cause either

-Vaginal agenesis-Vaginal agenesis

-Androgen insensitivity syndrome-Androgen insensitivity syndrome

-Turners syndrome (45, X0)-Turners syndrome (45, X0)

Amenorrhea, Amenorrhea, causescauses

Generalized pubertal delay e.g. Turner Generalized pubertal delay e.g. Turner syndromesyndrome

Normal puberty e.g. PCOSNormal puberty e.g. PCOS

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

Amenorrhea, Amenorrhea, managementmanagement

Hx. Hx. PE- These are probably the most important PE- These are probably the most important aspects in diagnosisaspects in diagnosisRemember to always rule out pregnancyRemember to always rule out pregnancyH & P suggestsH & P suggests

- Ovarian-axis problem- TSH, prolactin, FSH, LHOvarian-axis problem- TSH, prolactin, FSH, LH- Hirsuitism-Testosterone, DHEAS, Hirsuitism-Testosterone, DHEAS,

androstenedione and 17-OH progesteroneandrostenedione and 17-OH progesterone- Chronic ds.- ESR, LFT’s, BUN, cr and UAChronic ds.- ESR, LFT’s, BUN, cr and UA- CNS- MRICNS- MRI

Amenorrhea, Amenorrhea, managementmanagement

If H and P gives no clues to diagnosis-If H and P gives no clues to diagnosis-excitingexciting

Use step wise approach to diagnosisUse step wise approach to diagnosis

Evaluation of Secondary Amenorrhea

TABLE 4Causes of Amenorrhea

Hyperprolactinemia Prolactin ≤ 100 ng per mL (100 mcg per L) Altered metabolism

Liver failure Renal failure

Ectopic production Bronchogenic (e.g., carcinoma) Gonadoblastoma Hypopharynx Ovarian dermoid cyst Renal cell carcinoma Teratoma

Breastfeeding Breast stimulation Hypothyroidism Medications

Oral contraceptive pills Antipsychotics Antidepressants Antihypertensives

Histamine H2

receptor blockers Opiates, cocaine

Prolactin > 100 ng per mL Empty sella syndrome Pituitary adenoma

Hypergonadotropic hypogonadism Gonadal dysgenesis

Turner's syndrome* Other*

Postmenopausal ovarian failure Premature ovarian failure

Autoimmune Chemotherapy Galactosemia Genetic 17-hydroxylase deficiency syndrome Idiopathic Mumps Pelvic radiation

Hypogonadotropic hypogonadism Anorexia or bulimia nervosa Central nervous system tumor Constitutional delay of growth and puberty* Chronic illness

Chronic liver disease Chronic renal insufficiency Diabetes Immunodeficiency Inflammatory bowel disease Thyroid disease Severe depression or psychosocial stressors

Cranial radiation

Hypogonadotropic hypogonadism (continued) Excessive exercise Excessive weight loss or malnutrition Hypothalamic or pituitary destruction Kallmann syndrome* Sheehan's syndrome Normogonadotropic Congenital

Androgen insensitivity syndrome* Müllerian agenesis*

Hyperandrogenic anovulation Acromegaly Androgen-secreting tumor (ovarian or adrenal) Cushing's disease Exogenous androgens Nonclassic congenital adrenal hyperplasia Polycystic ovary syndrome Thyroid disease

Outflow tract obstruction Asherman's syndrome Cervical stenosis Imperforate hymen* Transverse vaginal septum*

Other Pregnancy Thyroid disease

*-Causes of primary amenorrhea only.Information from references 3, 6, and 15.

Abnormal MenstruationAbnormal MenstruationHere’s what you need to remember!!Here’s what you need to remember!!

Always R/O pregnancy, check papAlways R/O pregnancy, check papTry to differentiate anovulatory from ovulatory bleedingTry to differentiate anovulatory from ovulatory bleedingGood history and physical is key( this applies to Good history and physical is key( this applies to amenorrhea as well)amenorrhea as well)Do a focused work up based on your H & P rather than a Do a focused work up based on your H & P rather than a random set of studiesrandom set of studiesIn amenorrhea, where no indication of cause based on In amenorrhea, where no indication of cause based on

H & P, follow the stepwise algorithm for diagnosisH & P, follow the stepwise algorithm for diagnosisKnow the INDICATIONS for endometrial samplingKnow the INDICATIONS for endometrial sampling

Thank You

Thank You

Egypt

ReferencesReferences

Slides 25 and 26 courtesy of:Slides 25 and 26 courtesy of:

Master-Hunter T, Heiman D, Amenorrhea: Master-Hunter T, Heiman D, Amenorrhea: Evaluation and Treatment. AFP April 15Evaluation and Treatment. AFP April 15thth 2006.2006.