Menstrual Disorders

Geetha Kamath, M.D.

Dept. of Medicine
West Virginia University
 Definition
 Normal menstrual cycle involves hypothalamus-
pituitary-ovary and uterus and is 28 days
 Vaginal bleeding is abnormal (Abnormal
Uterine Bleeding--AUB) when:
 Volume is excessive or
 Occurs at times other than expected, including
during pregnancy or menopause
 Known as dysfunctional uterine bleeding (DUB)
when organic causes are excluded
 AUB
 Duration >7 days or
 Flow >80ml/cycle or
 Occurs more frequently than 21 days or
 Occurs more than 90 days apart or
 Intermenstrual or postcoital bleeding
 Terminology
 Menorrhagia: excessive flow
 Menometrorrhagia: excessive volume
 Oligomenorrhea: scanty flow
 Dysmenorrhea: painful menstrual cycles
 Causes of Menstrual Disorders
 Structural
 Pregnancy associated
 Hormonal and endocrine
 Hematologic and coagulation disorders
 Other
 Causes--structural
 Endometrial polyps
 Endometrial hyperplasia
 Endometritis
 Fibroids
 Intrauterine devices
 Uterine arterio-venous malformation (AVM)
 Uterine sarcoma
 Pregnancy related
 Implantational bleeding
 Ectopic pregnancy
 Spontaneous abortion [incomplete, missed,
septic, threatened]
 Therapeutic abortion
 Gestational trophoblastic disease
Hormonal and Endocrine causes
 Anovulatory (including polycystic ovary
syndrome)
 Ovarian cyst
 Estrogen-producing ovarian tumor
 Perimenopause
 Hormonal contraceptives
 Hormone Replacement Therapy
 Hypothyroidism
 Hematologic
 Von Willebrand’s disease (most common
inherited bleeding disorder with frequency
1/800-1000)
 Hemophilia
 Thrombocytopenia
 Hematologic malignancies (leukemia)
 Liver disease
 Other
 DUB (dysfunctional uterine bleeding): non-organic
causes, either ovulatory or anovulatory
 Fallopian tube cancer
 Trauma
 Foreign body
 Cervical bleeding--mets, cervicitis, cervical cancer
 Vaginitis--atrophic, cancer of vagina
 Endometrial cancer (10% of post-menopausal
bleeding)
 Evaluation of Abnormal Uterine
Bleeding (AUB)
Acute Chronic
History suggestive of: History:
 Pregnancy and related  Long standing abnormal
complications menstrual history
 Recent and Heavy  Symptoms of anemia,
bleeding hypothyroidism,
 Pelvic pain perimenopause
 Medications  Personal or family history

contributing to above of excessive bleeding

 AUB Examination
 Assess vitals/hemodynamic stability
 Look for features of anemia (pallor,
tachycardia, syncope)
 Look for features of hypothyroidism
 Look for metabolic syndrome (obesity,
hirsutism, acne)
 Pelvic exam for structural abnormalities:
fibroids, pregnancy, active bleeding—uterine
vs. cervical bleeding
 AUB Lab Studies
 Serum HCG to rule out pregnancy
 CBC and iron studies to assess severity of anemia
 TSH for thyroid disorders
 Coagulation studies (PT, PTT, platelet count, VWF) (primarily
for adolescents)
 Transvaginal ultrasound to look for fibroids and other
masses/lesions
 Endometrial biopsy to rule out endometrial cancer in
perimenopausal and chronic anovulatory cycles (primarily for
women >35 years with AUB and postmenopausal women)
 Sonohysterography is useful in diagnosis of anatomical lesions
which might even be missed with transvaginal ultrasound
 Treatment of Chronic Menorrhagia
for Most Causes (including DUB)
 Combined hormonal contraceptives (cyclical
or continuous)
 DMPA (depot medroxyprogesterone)
 IUD (Intrauterine devices)
 Treatment options continued
After excluding coagulopathy, pregnancy, or
malignancy:
 Progestins
 Estrogens including oral contraceptives
 Cyclic NSAIDS
 Dilatation and curettage (surgical)
 Endometrial ablation (surgical)
 Hysteroscopic endometrial resection (surgical)
 Treatment for Fibroids
 Surgical: Hysterectomy/myomectomy, uterine
artery ablation
 Medical: Suppression of gonadotropins
(danazol and leuprolide)
 Treatment: progestins
 Inhibits endometrial growth by inhibiting
synthesis of estrogen receptors, promotes
conversion of estradiol to estrone, inhibits LH
 Organized slough to basalis layer
 Stimulates arachidonic acid production
 Progestins preferred for those women with
anovulatory AUB
 Progestational Agents
 Cyclic medroxyprogesterone 2.5-10mg daily
for 10-14 days
 Continuous medroxyprogesterone 2.5-5mg
daily
 DMPA 150 mg IM every 3 months
 Levonorgestrel IUD (5 years)
 Estrogens
 Conjugated estrogens given IV every 6 hours
effective in controlling heavy bleeding
followed by oral estrogen
 For less severe bleeding, oral conjugated
estrogens 1.25 mg, 2 tabs qid--until bleeding
stops
 NSAIDS
 Cyclooxygenase pathway is blocked
 Arachidonic acid conversion from
prostaglandins to thromboxane and
prostacyclin (which promotes bleeding by
causing vasodilation and platelet aggregation)
is blocked
 Clinical Highlights
 Most common cause of AUB in reproductive
age is pregnancy related--so initial evaluation
must include pregnancy test.
 Pregnancy must be ruled out before initiating
invasive testes or medical therapy
 Clinical Highlights
 Endometrial biopsy is recommended for post
menopausal women
Or
 Younger women with history of chronic
anovulation >35 years of age
 Clinical Highlights
 Uterine cancer and endometrial hyperplasia
must be ruled out before medical therapy is
initiated in postmenopausal/perimenopausal
bleeding
 NSAIDS may reduce menstrual flow by 20-
60% in women with chronic menorrhagia
 Coagulopathy workup must be initiated in
menorrhagia in adolescents
 References
 ACOG Practice Bulletin #14, 2000
 American Journal Obstetrics and Gynecol
2005;193:1361
 Clinical Obstetrics & Gynecology 50(2):324-
353, June 2007
 Comprehensive Gynecology, 4th edition
 Harrison’s Principles of Internal Medicine, 14th
edition
 Karlsson, et al, 1995