Menstrual Disorders

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Menstrual Disorders

• Anna Mae Smith, MPAS, PA-C
• Lock Haven University
• Physician Assistant Program

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Definitions of Amenorrhea

• Amenorrhea absence of menstruation
• Primary Amenorrhea failure of menarche to occur
  before 16 years of age or within 4 years of
  thelarche
• Secondary Amenorrhea cessation of menses for at
  least 6 months in a premenopausal woman

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Amenorrhea

• Hypothalamic Dysfunction
• Pituitary Dysfunction
• Ovarian Failure
• Anatomic Abnormalities of the Reproductive Tract

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Hypothalamic Disorders

• Low FSH, LH
• Congenital syndromes
• Systemic stresses
• significant weight loss
• anorexia
• bulimia
• excessive exercise
• severe emotional distress

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Hypothalamic Disorders

• Destructive lesions or neoplastic lesions of the
  hypothalamus
• increased serum prolactin level
• Infiltrative or infective disorders
• sarcoidosis
• encephalitis

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Pituitary Disorders

• Elevated serum prolactin level
• r/o pharmacologic and physiologic causes of
  hyperprolactinemia
• tumor
• pituitary adenoma (micro or macro)
• Low serum prolactin level
• Sheehan syndrome
• head trauma
• destructive neoplastic processes

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Ovarian Failure

• Elevated FSH, LH
• Cytogenetic alterations
• Enzymatic defects
• Physical insults
• Immune disturbances
• Defective gonadotropin secretion or action
• Idiopathic

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Hypergonadotropic Amenorrhea

• 15 present with primary amenorrhea
• incomplete pubertal development
• irreversible
• 85 present with secondary amenorrhea
• some ovarian function may be preserved
• not always permanent
• 8 conceived after the initial diagnosis of
  gonadal failure was made

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Anatomic Abnormalities

• Incomplete mullerian development
• obstruction of outflow tract
• imperforate hymen
• transverse vaginal septum
• atresia of the cervix
• endometriosis frequently found also
• Asherman syndrome

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Other Causes of primary amenorrhea with no puberty

• Turners Syndrome
• Resistant Ovary
• Damaged ovaries - radiation, infections, trauma
• Kallmans Syndrome

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Diagnosis of Amenorrhea

• Pregnancy Test
• Progestin Challenge
• See handout

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Abnormal Uterine Bleeding

• Pregnancy
• Pelvic infection
• Anovulation
• Leiomyoma/polyps
• Adnexal pathology
• Endometrial hyperplasia
• Endometrial carcinoma

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Terminology of Abnormal Bleeding

• Oligomenorrhea bleeding at intervals 40 days
  that usually is irregular
• Polymenorrhea bleeding at intervals that may be regular or irregular
• Menorrhagia bleeding that is excessive in both
  amount and duration at regular intervals
• Metrorrhagia bleeding of usually normal amount
  but at irregular intervals

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• Menometrorrhagia bleeding that is excessive in
  amount, is prolonged in duration, and may occur
  at regular or irregular intervals
• Hypomenorrhea regular uterine bleeding in
  decreased amount
• Intermenstrual bleeding bleeding that occurs
  between what is otherwise regular menstrual
  bleeding

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Pre-puberty Bleeding

• Premenarcheal- bleeding occurs prior to puberty-
  ABNORMAL
• Differential Diagnosis
• Trauma
• Cx or vag Ca
• Foreign body
• Exogenous estrogen
• Sporadic gonadotropin surge

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Differential Diag of premenarchal bleeding

• Precocious Puberty
• Neoplasm affecting endocrine function
• Ovarian
• estrogen(granulosa cell)
• hCG(embryonic Ca or choriocarcinoma)
• Adrenal tumors
• CNS tumors
• Albrights Syndrome
• von Recklinghausens Dz

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Differential Diag of premenarchal bleeding

• Precocious Puberty
• Adrenal Hyperplasia
• Hypothyroidism
• Idiopathic
• GI or GU tract bleeding

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Bleeding in the Reproductive Years

• DUB - dysfunctional uterine bleeding- Only use if
  no other organic cause of bleeding is found
• Organic Pathology
• Pregnancy (intrauterine or ectopic)
• Neoplasia
• Genital tract - Cx, endometrial,ovarian, tube etc
• Other - CNS, adrenal, thyroid

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Organic Pathology Causing Bleeding in Repro Yrs

• Polyp - Cx or endometrial
• Leiomyoma
• Adenomyosis
• Infection - cervicitis, endometritis
• Endocrine dysfunction
• Pituitary/hypothalamus
• Adrenal
• Thyroid

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Organic Pathology Causing Bleeding in Repro Yrs

• Iatrogenic
• IUD
• Drug use
• hormones
• nonhormonal- effects dopamine metab
  (phenothiazines,TCAs,reserpine,
  alpha-methyldopa)
• Blood dyscrasias

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Physiologic Correlates of Bleeding

• Anovulatory bleeding estrogen breakthrough
• Tx Provera 10 mg days 16-25 of cycle
• NSAIDs
• Midcycle bleeding estrogen withdrawal
  (ovulatory DUB)
• Tx ethinyl estradiol for 3 days before to 2
  days after ovulation
• OCPs

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Anovulatory Bleeding

• May confirm by lack of premenstrual symptoms
• BBTs
• May occur expectedly in puberty climacteric
• Symptom of an endocrine disturbance
• Tests of thyroid, hypothalamic, pituitary, and
  adrenal function are warranted
• TSH, FSH, LH, prolactin, and dehydroepiandrosteron
  e (DHEA)

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Anovulatory Bleeding

• Anovulatory bleeding associated with signs of
  androgen excess (on PE), serum testosterone and
  17-hydroxyprogesterone levels must also be
  obtained

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Ovulatory DUB

• Endometritis - tender uterus - tx with
  antibiotics
• Endometrial biopsy, cultures
• presence of plasma cells within the endometrial
  glands and stroma

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Ovulatory DUB

• If endometritis is ruled out think
• Anatomic abnormalities of the
• myometrium
• endometrium
• endocervix

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Ovulatory DUB

• Premenstrual spotting deficient progesterone
  production by the corpus luteum
• Tx Provera 10 mg days 16-25 of cycle
• OCPs
• Postmenstrual spotting irregular endometrial
  shedding
• Tx OCPs
• Estrogen
• NSAIDs

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Evaluation of Abnormal Bleeding

• Serum HCG
• Pelvic ultrasound
• Endometrial biopsy
• Serum CA-125
• Endocrine tests
• Cultures for STDs
• Diagnostic hysteroscopy
• Coagulation studies

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Treatment of Abnormal Bleeding

• Cyclic progestins (Provera 10 mg qd days 16-25 of
  cycle)
• Oral contraceptives (OCP qid x 5-7 days)
• IV or oral estrogen followed by combination oral
  contraceptives (Premarin 25 mg IV q4h x 3-4
  doses)
• Surgical hysteroscopy
• Endometrial ablation

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Treatment contd

• GnRH agonist (Lupron)
• Hysterectomy
• Laparotomy with myomectomy

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Postmenopausal Bleeding

• Bleeding that occurs 6 months after the cessation
  of menstrual cycles
• Increase in endometrial carcinoma in the
  postmenopausal age group
• All need an endometrial biopsy!

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Causes of Postmenopausal bleeding

• Neoplasm
• Endometrial, vulva, vaginal, cx, tubes, ovary
• Endometrial hyperplasia
• Polyp
• Estrogen - exogenous
• endogenous(adipose tissue or neoplasm)
• Trauma - vagina

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endometrial cavity is opened to reveal lush
fronds of hyperplastic endometrium
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Causes of Postmenopausal bleeding

• Infection
• endometritis
• vaginitis (atrophic)
• Vulvar dystrophy
• Idiopathic
• Non-genital tract
• urinary or GI tract

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Treatment of Postmenopausal Bldg

• Endometrial biopsy
• DC
• TAH

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