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Good MorningMonday, August 8th, 2011

Normal Menstrual Cycle

Normal Menstrual CycleNormal cycle lasts: 26 to 30 days, but may vary from 21 to 35 daysNormal menstrual flow lasts: 3 to 7 daysA period lasting longer than 10 days is considered pathologicAverage amount of blood loss per cycle:30 to 40mlMore than 80ml is considered pathologicAbnormal Vaginal BleedingTerms:MenorrhagiaHeavy (>80ml) or prolonged bleeding (>7 days) that occurs at regular cyclic intervalsMetorrhagiaIrregular vaginal bleeding (acyclic)MenometorrhagiaHeavy vaginal bleeding occurring at irregular intervalsPolymenorrheaFrequent vaginal bleeding at intervals more often than every 21 days

Abnormal Vaginal BleedingAbnormal vaginal bleeding= all cases of irregular, heavy, or frequent bleeding

Dysfunctional uterine bleeding = bleeding that is not due to underlying anatomic abnormalities or systemic conditions*Most frequently caused by chronic anovulation and immaturity of the hypothal-pit-ovarian axisDiagnosis of exclusionFirst 2-3 years after menarche, axis is not mature and most cycles are anovulatory7

Differential DiagnosisMost common is anovulatory bleeding due to immature hypothal-pituitary-ovarian axis (DUB)Anovulatory bleeding is the most common cause of acyclic bleeding and may be associated with:SportsStressDisordered eatingEndocrinopahties (thyroid problems, DM, Cushings)MenorrhagiaMay suggest bleeding disorders or uterine pathologyThe most common bleeding disorders are:Thrombocytopenia (usually ITP)von Willebrand disease (occurs in 95% of women)Usually a history of heavy bleeding from first menstrual periodvon Willebrand DiseasevWf role in hemostasis by binding to platelets and endothelial components; carrier protein for Factor 8Presents with easy bruising, skin bleeding, prolonged bleeding from mucosal surfaces (ex: OP, GI, uterine)Nose bleeds >10 minutesBleeds after tooth extractionPresentationVaries from subtle onset of fatigue due to iron deficiency anemia to acute mental status changes or syncope caused by severe blood loss (like our patient!)HistoryMenarcheUsual pattern of bleedingFrequency and duration of mensesPresence of menstrual crampingLMPSexual historyAny STDsROSSymptoms of PCOS, thyroid disease, bleeding disorders, hypothalamic amenorrhea

MedicationsDepoOCPsIUDsPsychotropic medicationsRisperidoneIllicit drugsHerbsDietary supplementsExamVital signsInclude orthostatic measurements Look for signs of conditions in your DDx:PCOSThyroidBruising or petechiaeConsider bimanual and pelvic examPelvic U/S in those who cant tolerate and exam*LabsCBCUPT (exclude pregnancy in everyone!!)PTPTTvon Willebrand panelShould be drawn before hormonal therapies start because estrogen increases concentrationPlatelet function assayGC/Chlamydia (in sexually active)TSHTestosterone, DHEAS (if suspect PCOS)*ManagementPerimenarchal DUB requires only reassurance and iron therapyNSAIDS can help reduce blood lossCombination oral contraceptivesBleeding usually decreases significantly with 24 to 36 hours of hormonal therapyEstrogen = promotes clotting and causes endometrial proliferationProgestin = stabilized the endometrial lining*Surgery is rarely necessary (endometrial ablation, hysterectomy)

Iron TherapyKids: 3-6 mg elemental Fe/kg/dayAdults: 60-100mg elemental Fe BIDLess GI irritation when given with or after mealsVitamin C may enhance absorptionAntacids may decrease absorptionHgb should rise after 1-2 weeks of treatmentHgb should return to normal at 6-8 weeksTx for 6 months

Noon ConferenceImmunizations, Dr. Begue