ABNORMALITY OF MENSTRUATION

Prof. Dr.Johanes C. Mose,Sp.OG(K)

Abnormality :

 Cycles
 Period
 Amount of bleeding
 Pain associated with menses
Types of abnormalities

Amenorhea, pseudomenorhea/criptomenorhea,
Hipomenorhea, oligomenorhea, hipermenorhea,
menorhagia, polymenorhea, metrorhagia,
dismenorhea, combination.
The abnormalities is depend on the period of life

 During teenagers : Dismenorhea, irregularity,

DUB

 During reproductive time : Menorhagia,

metrorhagia, DUB, amenorhea, oligomenorhea.

 During premenopause : Irregularity, amenorhea,

oligomenorhea, DUB.
Etiology :

Disturbance on hypothalamus - hypophysis -

ovarial - endometrial axis

 Systemic diseases
 Degenerative diseases
 Psychological disturbance
 Neoplasm / carcinoma
 Radiation
 Blood disease
 Nutritional disorders
The disturbance on physiology of cells
neurotransmitter
neurohormonal
receptor

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 14 years old
2. Until 16 years old with secondary sexual
development, but not reach menarche
3. Had a menstruation before, but than not
having a menses in 3 cycles in role on in
six months.
Classification

 Primary amenorhea : Not have reach menarche

at all
 Secondary amenorhea : Had a menstruation
before than stop.
a. Physiologically : Puerpuerium
Breast feeding
During pregnancy
Menopause
b. Pathologically : Other causes.
Amenorhea could be followed by galactorhea and
hirsutism.
Causes of Amenorrhea
 Disorders of sexual differentiation
Distal genital tract obstruction
Gonadal dysgenesis
Ambiguity of external genitalia
 Other peripheral causes
Pregnancy
Gestational trophoblastic disease
Aseherman’s syndrome
Causes of Amenorrhea

 Chronic anovulation or ovarian failure

Due to CNS-hypothalamic-pituitary dysfunction
Due to inappropriate feedback (PCOS)
Due to thyroid and adrenal disordes
Persumtive ovarian failure
 BIOCHEMICAL EVALUATION OF
AMENORRHEA

Measure FSH,PRL,TSH

Hisgh TSH High PRL High FSH Normal TSH, PRL,Normal or low FSH
Primary Normal TSH Evaluate for
Hypothyroidism Gonadal failure Hirsutism No Hirsutism
Evaluate Measure T,DS Measure T
hyperprolactinemia

T>200ng/dl Normal or mildly high T Normal or mildly high T Mildly high T Normal T
or DS>7,0 ug/ml DS 5,0-7,0 ug/ml and/or DS (normal or high LH) (normal or high LH)
(normal or high LH)
Evaluate for Evaluate for
neoplasm “adult-onset” CAH ?Evaluate for “adult-onset” CAH
DISMENORHEA

Definition
Pain that feel just before or on menstruation

Classification :
 Primary dismenorhea/functional/idhiopatic :
pain that have no pathological causes
 Secondary dismenorhea
Caused by factor that could be found
Etiology :
Prostaglandin theory F2-

Prostaglandin elevated the end of menstrual

cycles caused contraction of uterus
ischemia pain.

Secondary dismenorhea
Could be caused by :
- Pelvic infection
- Endometriosis
- Myoma
- IUD
- Endometrial polyp
Treatment : Symptomatic
Endocrinology
Operative
Psychology

Symptomatic treatment :
- Analgesic
- Sedative
- Antispasmodic
- Diuretic
- Light exercises
- Bed rust
- Oral contraceptive
- Tocolytic
- Panasacral neurectomy
DISFUNGTIONAL UTERUS 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 examination
2. Anovulation diagnosis
Basal temperature : monophasic
Progestin level : low
Gonadotropin level : LH low
Hyperfunction of adrenal : high testosteron
Hypothyroid : high TSH
Endometrial Biopsy : atrophy, proliferate
Mittelschmeric : absent
Menstrual 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 delivery
c. Senility

Diagnosis :
 Molimina menstrualia
 Hematokolpos Hematometra
Hematosalphing

Treatment :
Incision/excision of blockade hymen
II. Menstruation Praecock

Definition
Bleeding 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 between
Estrogen and progesterone
Oligomenorhea
Menstruation rare, long cycles more that
2 months

Caused by :
- Prolonged follicular phase
- Prolonged luteal phase
- Both of them
Always 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
Metrorhagia
Irregular bleeding do not associated with
menstrual cycles.

I. Caused by pregnancy
- Abortion
- Ectopic pregnancy

II. Not caused by pregnancy

Usually hormonal or organic.