Menstruation & AUB
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Transcript Menstruation & AUB
Disorders of
Menstruation /
Abnormal Uterine
Bleeding
Tory Davis, PA-C
Menstruation
Shedding the uterine lining
(endometrium) if pregnancy does not
occur.
Necessary (in the absence of
hormonal regulation) to insure the
endometrium does not become
hyperplastic.
Terminology
Amenorrhea—lack of menstrual bleeding
– Primary—no menses by age 16
– Secondary—absence of 3 or more expected
menstrual cycles
Break-through bleeding (BTB)
unexpected bleeding usually occurring while
a woman is on exogenous hormonal
medication (eg OCPs, patch, or ring)
Terminology (cont.)
Menorrhagia—heavy menstrual bleeding.
Prolonged or excessive menstrual blood
loss with regular cycles
Metrorrhagia—irregular, frequent bleeding
Menometrorrhagia—irregular menses with
prolonged or excessive blood loss
Midcycle bleeding—light menstrual
bleeding occurring in ovulatory women at
the midcycle estradiol trough
Terminology (cont.)
Oligomenorrhea-- menstrual
bleeding/menses occurring less frequently
than 36 days apart
Polymenorrhea—frequent menstrual
bleeding/menses occurring more frequently
than 21 days apart
Contact bleeding/post-coital bleeding
Dysmenorrhea- painful menstrual bleeding
Physiologic
Requirement?
Hormonal fluctuations of the cycle
allow the monthly release of a mature
ovum from the ovaries and prepares
the endometrium for implantation.
Controlled by GnRH from the
hypothalamus, FSH and LH from the
pituitary, E2 from the ovary, and P4
from the corpus luteum
Normal Menstrual
Cycles
Mature, ovulatory women
– 28-29 day average
– 21-36 day range
– 2-7 days duration
– 20-80 cc of blood loss per month
Cycle Variation
Women in their middle reproductive
years have the most predictable cycles
More pronounced cycle to cycle
variability in the 5-7 years after
menarche and 6-8 years before
menopause
Cycle Variation (cont.)
Adolescents
– Majority range 21-48 days
– Usually anovulatory
– Mean time from menarche until half the cycles
are ovulatory depends upon the age of
menarche
– 12 yrs 1yrs till half cycles are ovulatory
– 12-13 3yrs
– >13 4.5 yrs
Cycle Variation (cont.)
Perimenopause
– Cycles initially shorten
– Ultimately (apparently) lengthen, as an
entire cycle will be skipped
Average age of menopause is 51
– Cessation of menses for one year
Impact on Health
75% of women experience physical
changes associated with menses
PMS (Premenstrual syndrome)
PMDD (Premenstrual dysphoric disorder)
Direct and indirect health care costs
– Visits to ED, clinic, or office
– Time lost from work
Quality of Life Issues
Many women seek healthcare related
to menstrual problems
– National health survey revealed 66% of
women sought care
– 31% had stayed in bed for more than ½
day at least once during the previous year
– 12% of all ED visits
PMS
Psychoneuroendocrine d/o with
biological, social and psychological
impacts
Up to 75% of women experience some
level of recurrent sx
Up to 5% may experience severe sx
and distress
Common PMS Sx
Headache
Breast pain
Bloating
Irritability
Fatigue
Crying
Abd pain
Clumsiness
Sleep alteration
Labile mood
Social withdrawal
Libido change
Appetite change
Requisite Symptoms
for PMDD Diagnosis
Depressed mood
Anxiety/tension
Mood swings
Irritability
Decreased interest
Concentration
difficulties
Fatigue
Appetite changes/food
cravings
Insomnia/hypersomnia
Feeling out of control
Physical symptoms
5/11 symptoms
needed for
diagnosis and
Sx disrupt daily
functioning
PMS/PMDD Tx
Limit caffeine, tobacco, alcohol and
sodium
Frequent high-complex carb meals
CBT, stress management, aerobic
exercise
PMS/PMDD Tx
SSRIs (ie: fluoxetine) 14 days prior to
onset of menses
OCPs..not really effective
Chaste berry and St John’s wort- more
effective than placebo but less than
fluoxetine
Dysmenorrhea
Painful menstruation- when pain
prevents normal activity and requires
medication
Pain starts when bleeding starts
Prostaglandin activity
Emotional/psychological factors
Dysmenorrhea tx
NSAIDs, starting a day before period
– Ibuprofen, naproxen
Anti-prostaglandins much less
effective after pain is established
Continuous heat to abd
OCPs for 6-12 months have lasting
benefit
Abnormal Uterine
Bleeding
Menorrhagia
Oligomenorrhea
Metrorhhagia
Polymenorhhea
Menometrorhhagia
Oligomenorrhea
Contact bleeding
Ddx of Abnormal
Uterine Bleeding
Blood Dyscrasias
Anatomic causes of bleeding, including
pregnancy
Anovulation
Malignancy
Non-uterine causes of bleeding
AUB work-up
Hx
PE with cytology
Pelvic ultrasound
Endometrial biopsy
Hysteroscopy
D & C
Blood Dyscrasias
Von Willebrand
Idiopathic thrombocytic purpura (ITP)
Leukemia
Clotting factor deficiencies
Anatomic causes
Pregnancy—cessation of menstrual
bleeding for 40 weeks
– 1 in 5 pregnancies end in spontaneous abortion
– First symptom is usually bleeding
Gestational trophoblastic disease (molar
pregnancy)
– Non-viable pregnancy with a large, grapelike
placenta that sloughs off and causes heavy
bleeding
Infection
– Cervicitis—leads to bleeding from the cervix
– Endometritis—leads to sloughing off of
endometrial blood and mucous
Anatomic causes
(cont.)
Endocervical or endometrial polyps
– Esp post-coital bleeding
IUD
– Bleeding likely with Paragard, extremely rare
with Mirena (progestin-containing)
Leiomyoma (fibroids)
– Subserosal (in wall of myometrium)
– Intramural (most common “bump on top”)
– Submucosal (can be pedunculated)
Leiomyomas (Fibroids)
Benign neoplasms arising from uterine wall
smooth muscle cells
20-25% of reproductive age women
Can be small to quite large, single or
multiple. Surrounded by pseudocapsule.
Often asx, but can cause metrorrhagia,
menorrhagia, dysmenorrhea and infertility
Cause unknown, but hormone responsive
Fibroid Sx
Prolonged, heavy bleeding, can cause
anemia
– (which type?)
Pain- from vascular compression
Sensation of fullness, heaviness in pelvis
Infertility or spontaneous abortion
PE:
– Distorted uterine contour
– Confirm with ultrasound
Fibroid Tx
Depends on sx, age, parity,
reproductive plans, general health, and
size/location of leiomyomas
GnRH agonists- to shrink fibroid
OCPs control bleeding but do not treat
the fibroid
Progestin-releasing IUD for multiple
small leiomyomata
Fibroid Tx - Surgical
Myomectomy- preserves fertility, high risk
for fibroid recurrence
Hysterectomy- eliminates sx and chance of
recurrence. Also eliminates uterus.
Uterine fibroid embolization (UFE)
– Embolic occlusion of uterine arteries
– As effective as above, few recurrences, few
major complications
Anovulation
Patient History—very important to
diagnosis
– Ovulatory cycles—consistent number of
days from beginning of one cycle to the
next, breast tenderness, and
dysmenorrhea usually present
– Anovulatory cycles—variation in
number of days per cycle, no breast
tenderness, and dysmenorrhea is not
consistent from one cycle to the next
Anovulation
Hypothalmic disorder related to:
– Stress
– Diet
– Exercise
– Body fat
Pituitary-ovarian axis very sensitive to
any bodily changes
Anovulation:
Endocrinopathies
Thyroid
– Both hypo- and hyperthyroidism may
present with AUB
– TSH
Anovulation,
endocrinopathies
Prolactin
– Pepperell evaluated 304 patients with
oligoamenorrhea and found 7.6% had increased
prolactin
– Interrupts menstrual function by inhibiting
pulsatile release of GnRH
– Note: causes for falsely elevated prolactin levels
Recent breast exam or breast stimulation
Recent pelvic exam
Anovulation: POF
Premature Ovarian Failure (Early
Menopause)
– Diagnosed if woman of child-bearing age
develops amenorrhea and FSH level is
found to be greater than 35
– This is an indication that the ovaries are
no longer producing sufficient hormone
levels to allow ovulation to occur
Other Causes of
Anovulation
Any medication that affects the
cytochrome P-450 cycle, eg
psychotropic drugs
Ovarian tumors that produce steroids:
– Granulosa cell tumors
– Sertoli Leydig cell tumors
Malignancy as a
Cause of AUB
Uterus—endometrial cancer
Cervix--severe dysplasia, carcinoma in
situ, or invasive cancer will lead to
bleeding.
Fallopian tubes—much less common
Ovarian—not usually associated with
bleeding
DUB
“Dysfunctional uterine bleeding”
Abnormal uterine bleeding with
pathologic causes ruled out
So..you’ve done all that stuff, and it’s
all okay
Usually tx with hormones (ie OCPs) to
control bleeding
Non-uterine causes
Genital neoplasms of the vulva or vagina
– To avoid missing vaginal lesions, stainless steel
speculum blades should be rotated on removal
to fully evaluate the vaginal mucosa
– Better: use plastic speculum with good light
source
Genital trauma/foreign objects
Rectal bleeding or urinary tract source
Evaluation
History
– Menstrual pattern (duration, changes in
quality, color of menses)
– Dysmenorrhea, mittleschmerz, breast
changes
– Post-coital spotting
– Dietary practices, change in weight,
exercise, stress
– Evidence of systemic disease
Evaluation (cont.)
Physical Exam
–
–
–
–
–
–
–
Vital signs, height, weight, body phenotype, BMI
Skin, hair (acne, hirsutism pattern)
Fat distribution, striae
Thyroid
Breast exam to check for galactorrhea
Complete pelvic exam
Tanner stage for teens
Evaluation--testing
All patients:
– Pregnancy test
– CBC with platelets
– Recent Pap
Over 35 yrs:
– Endometrial sample
Documented drop in
hgb <10
– PT, PTT
– Bleeding time
As indicated:
–
–
–
–
–
–
TSH
Prolactin
Testosterone
LH/FSH
17-OH progesterone
Overnight
dexamethasone
suppression test or 24
hr urinary free cortisol
– Hysteroscopy or
ultrasound
Proposed Treatment
Scheme
Begin evaluation and diagnostic
testing, rule out pregnancy, check hgb
Hospitalize for low hgb (<7), and
strongly consider blood dyscrasia,
submucosal fibroid, or malignancy
Acute Bleeding: Control
Oral progestins:
– Micronized Progesterone 200 mg (Prometrium)
or Medroxyprogesterone 10 mg (Provera) or
Norethindrone 5 mg (Aygestin)
– 1 po q4 hrs or until bleeding stops, then
– 1 qid x 4 days
– 1 tid x 3 days
– 1 bid x 2 weeks, then
– Cycle monthly with progestin or low dose oral
contraceptive
AUB Long Term Control
Cycle with low dose OCP, patch, or vaginal
ring
Cycle with a progestin, eg Prometrium
Use of progestin-containing IUD (Mirena)
Choice depends upon:
–
–
–
–
Contraceptive need
Smoking status
Medical history
Patient preference
Long Term Control
Danazol or other androgen agents will shut
down the hypothalamic-pituitary-ovarian
axis
GnRH analogs (Lupron, Nafarelin) (x 6
months)
Ibuprofen and other NSAIDs decrease
bleeding and cramping
Endometrial thickness of 4 mm or less is
needed to eliminate intermenstrual bleeding
Endometrial Ablation
Uterine thermal balloon
–
–
–
–
Out-patient procedure
Regional anesthesia (spinal or epidural)
Balloon catheter inserted into uterus
Very hot fluid (87C) is inserted for 8 minutes
Post-Procedure
– Cramping, bleeding for 1 week, serous
discharge for 4-6 weeks
– Amenorrhea is the intended result
Endometriosis
Abnormal growth of endometrial tissue
in locations other than the uterine
lining
3-10% of women of reproductive age
30% of infertile women
Pathogenesis
Cause unknown, but theories:
Retrograde menstruation
– Viable endometrium shed during menses,
flows thru fallopian tubes to peritoneal
cavity
– Solid theory that does not explain all
cases (ie: endometriosis in nonmenstruating women or in non-peritoneal
endometriosis)
Pathology
This is a SURGICAL diagnosis
Characteristic diagnostic surgical gross
appearance
Small petechial lesions to larger “powder
burn” lesions 5-10 mm
– Multiple lesions
On ovary, can enlarge to several
centimeters
– Endometriomas, or “chocolate cysts”
Implantation
MC site: ovary
Also round and broad ligaments,
uterus, fallopian tubes, sigmoid colon,
appendix
Can implant on bowel, bladder, ureters
– Or deep in tissue; cervix, posterior fornix,
wounds
Also brain, thoracic cavity...
Pathophys
Pelvic pain- secondary to hormonal
stimulation of endometrial tissue
Implants enlarge and then bleed
– But implants are surrounded by fibrotic
tissue that prevents escape of
hemorrhagic fluid
Leads
effects
to inflammation, adhesions, mass
BUT
Many pts with endometriosis do not
have significant pain
Maybe pain is assoc with depth of
invasion?
History
Infertility
Dysmenorrhea
Dyspareunia
Constant pelvic pain or low sacral back
pain
Physical
Tender nodules in posterior fornix
Pain with uterine motion
Or – most likely- normal exam
Diagnosis
What kind of diagnosis is it?
Can suspect and even tx based on
clinical findings
But if you need to know, go in- usually
laparoscopically
No need for other studies usually
Endometriosis Tx
Take into account:
– Desire for fertility
– Age
– Symptoms
– Stage of disease
Tx
Analgesics (ibu)
Hormones
– OCPs or progestins
– Danazol- prevents gonadotropin release, inhibits
midcyle LH and GSH. Androgenic side fx
– GnRH agonists (Lupron)- with continuous admin,
suppresses gonadotropin secretion
Assisted reproduction when desired
Prognosis
Can offer significant relief from sx
Can help achieve pregnancy
Cannot cure
– Although extensive surgery can come
close
– Conservative surgery has 10-35%
recurrence
Amenorrhea
Absence of menses
Primary amenorrhea- no menses by age 16
with otherwise nl development
Secondary amenorrhea- absence of
menses for 3 or more cycles or 6 months in
a previously menstruating female
– MC cause??
– 3% in genl population
– 100% under extreme stress
Examples?
Why bother?
Dx and tx amenorrhea important
– Implications for future fertility
– Risks of unopposed estrogen or
hypoestrogen
Ddx
Hypothalamic defects
– Abnl GnRH pulse discharge, transport
– Congenital GnRH deficiency
Idiopathic
hypogonadotropic hypogonadism
Pituitary defects (less common)
– Congenital or acquired
ie
pituitary adenomas
Ddx
Ovarian Dysfunction
– Gonadal dysgenesis- MC cause of
primary amenorrhea
ie:
Turner’s syndrome
– POF
– PCOS
XY karyotype (androgen insensitivity
syndrome)
Work-up
Download Amenorrhea pdf posted to
shared files
Progesterone challenge
Indirectly determines if ovary is
producing estrogen
If endometrium has been primed,
exogenous progestin will produce
menses
Tx
Desiring pregnancy?
– Ovulation induction
Not desiring pregnancy?
– If hypoestrogenic, combo tx with estrogen and
progesterone to maintain bone density and
prevent genital atrophy
– Normal progestin challenge: needs occasional
progestin to prevent endometrial hyperplasia and
cancer
– OCPs work well for either, and can decrease
hirsutism
– Calcium, too!
Infertility vocab
Infertility: Inability of a couple to conceive
for 12 months. (implies decrease in ability
to conceive)
– Primary vs secondary
Sterility: intrinsic inability to conceive
Fecundity: probability of achieving live
birth from one menstrual cycle
– Fecundability- likelihood of conception per
month
Very few infertile patients are sterile (1-2%)
Epi
13% of women (range 7-28%, age
dependant)
Incidence of primary and secondary
infertility increasing
– Why?
90% of couples having regular unprotected
intercourse will conceive in 1 year
Normal fecundability 20-25%
Infertility etiology
Either or both partners
– Cause found in 80% with even split
between partners
So start with thorough hx of conception
attempts and thorough hx of BOTH
partners
Key Aspects
Sperm
Oocyte- ovarian reserve and ovulation
Transport- fallopian tubes
Implantation- uterus
Dudes
History
– Prior paternity
– Congenital abnormalities or undescended testes
– Prev surgery or infections
PE
– Varicocele (MC cause)
Semen analysis
– Sperm count
– Motility
– Morphology
Chicas
Hx
– Menarche
– Cycle length and characteristics
– S/s systemic ds (hypothyroid)
– Exercise, weight
– Age
Girl exam
Pelvic, pap, etc
Confirmation of ovulation
– History
– U/S ovulation confirmation
– Basal body temp
– Cervical mucus monitoring
Pelvic U/S, hysterosalpingogram,
maybe laparoscopy
Treatment
Understanding that infertility can be a
devastating diagnosis
Emotional roller coaster
Damaging to self-image, relationships,
intimacy
Tx
Sperm factor- can use donor sperm or
intrauterine insemination using “prepared”
sperm
Ovulatory factor
– Clomiphene citrate (Clomid) for ovulatory
induction
– Good place to start
– IVF (most invasive/expensive)
Referral is most appropriate