Transcript Menstrual Cycle Disorders

Menstrual Cycle Disorders
Karen Estrella H.
Pediatric PGY-2 SBH
Nov/2010
Objetives
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Introduction
Normal physiology
Definitions
Menstrual Cycle disorders
– Amenorrhea
– Dysfunctional Uterine Bleeding
– Dysmenorrhea
Introduction
• Menarche:
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Median age: 12.7 yrs
African-american earlier than Caucasian
2-2.5yrs after breast development
Anovulatory cycles: 1st 1-2yrs of onset (55-82%)
• For 5 yrs (10-20%)
• Duration:
– Between 21 and 35 days (mode: 28)
– Lasting: 3-7days
– Blood lost: 30-40ml
Physiology
Physiology
Definitions
• Amenorrhea:
– Primary: absence of menarche by age 16 in the presence
of normal pubertal development (Tanner 4-5)
• Or: lack of menses by age 14 in absence of pubertal development
– Secondary: absence of 3 consecutive menstrual cycles or 6
months of amenorrhea
• Menorrhagia: normal intervals with excessive flow
– Cycles more than 8days, > 80ml
• Metrorrhagia: irregular intervals with excessive flow
• Oligomenorrhea: menstruation ocurring more than
every 35 days to 6 months
Menstrual Cycle Disorders
Amenorrhea
Amenorrhea
• Classification:
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2.
3.
4.
With pubertal delay
With normal pubertal development
Genital abnormalities
Hyperandrogenic anovulation
Amenorrhea
1. With pubertal delay
B
A. Hypergonadotropic hypogonadism
– OVARIAN FAILURE
• Turner
• XY gonadal dysgenesis
• Autoinmmune oophoritis
• Exposure to chemo or
RT(alkylating)
• 17 alpha hydroxylase
deficiency
Elevated FSH
A
Amenorrhea
1. With pubertal delay
B. Hypogonatropic hypogonadism
PITUITARY:
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Adenoma
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Prolactinoma
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Craniopharyngioma
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Hemochromatosis
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Hypothyroidism
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Breast stimulation
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Sx
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Phenothiazines, opiates
– (-PRL inhibitor factor)
Low or normal FSH
HYPOTHALAMIC:
• Suppresion:
– Stress
– Malnourishment
• Wt loss < 15% of ideal body
wt
– Strenous exercise
• Body fat < 22%
• If prior to menarche, each yr
of training delays onset by 5
months
– Prader-Willi
– Kallman
• Migration olfatory and GnRH
neurons)
Amenorrhea
2. with normal pubertal development
• Pregnancy
• Chronic diseases
– Exc IBD, DM, hypothyroidism, anorexia
• Use of hormonal contraceptive
– Progestational effect
• Uterine synechiae (Asherman sd)
• Sheehan sd.
Amenorrhea
3. Genital tract abnormalities
• Outflow tract-related:
– Imperforate hymen
– Transverse vaginal septum
– Agenesis of the vagina, uterus:
• Mullerian Agenesis: breasts, (+) pubic and axillary hair
• Testicular feminization (x-linked defect androgen receptor): breast,
(-) pubic axillary hair
Amenorrhea
4. Hyperandrogenic anovulation
• Hirsutism, acne, rarely
clitoromegaly
To be r/o:
1. PCOS (polycystic ovarian
syndrome)
– Most common
2.
3.
Ovarian and adrenal tumor or
adrenal enzyme deficiency
Obesity
EVALUATION
Primary amenorrhea
Presence of breasts
TSH
PRL
MRI brain
testosterone
Enzymatic defect
Hormone replacement
Surgery
Secondary amenorrhea
>100ng/ml
DHEAS: > 700ng/ml
Testosterone >90ug/ml
Asherman
Abd-pelvic MRI
17OH progesterone
Hirsutism: spirinolactone 50mg po TID
Evaluation: Secondary amenorrhea
• Progesterone challenge test:
– Oral medroxyprogesterone acetate for 5-10 mg QD for 510 days), or IM 200mg x1.
• POSITIVE TEST: withdrawal bleeding 2-7 days after
– +uterus
– +estrogen stimulation: ovaries ok
• Estrogen-progesterone challenge test:
– Oral conjugated estrogen (1.25 mg) or 2 mg estradiol qd
for days 1 through 21 with oral medroxyprogesterone
acetate (10 mg) on days 17 through 21.
• POSITIVE TEST: withdrawal bleeding 2-7 days after
– +uterus
– Insufficient estrogen stimulation
Dysfunctional Uterine Bleeding
Dysfunctional Uterine Bleeding
• Prolonged # of days of bleeding or excessive
bleeding
• Most common: anovulation
– the lack of progesterone secretion increases risk
of endometrial hyperplasia
High estrogen levels
Bleeding is prolonged,
irregular and
sometimes profuse
Adolescents
Obese
DUB: Differential dx
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Pregnancy
STD’s
PID
Foreign bodies
Cervical neoplasia
Coagulation defect: vWF
DUB:
Treatment
DYSMENORRHEA
Dysmenorrhea
(painful menses)
Primary:
• Decrease of progesterone
levels al end of luteal phase:
lysosomal membranes are
unstable::::release enzymes
formation:
Prostaglandins
Keep increasing during luteal and
menstrual phases
Uterine hypercontractibility
Tissue ischemia
Nerve hypersensitivity
(just before or 1st days of menses)
Secondary:
• Associated with pelvic
pathology:
– Endometriosis
– Miomas
– PID
– STD
– Genital tract obstruction
(Later age, Menorrhagia,
Dyspareunia, Pain with defecation,
worsening with every cycle or midcycle, symptoms that persist after
menses have finished)
Dysmenorrhea: Treatment
• Inhibiting prostaglandin synthesis:
– Ibuprofen: 400-600mg po q4-6hrs
– Naproxen 500mg load then 250mg po q6-8hrs
• Started on 1st day of bleeding
• Prevent ovulation and decrease endometrial
growth
– Oral contraceptives
• 30-35mcg combined estrogen-progestin x4-6months
• Laparoscopy
SUMMARY
References
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http://pedsinreview.aappublications.org/cgi/reprint/13/2/43?maxtoshow=&hits=1
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http://www.aafp.org/afp/2006/0415/p1374.html
http://www.wrongdiagnosis.com/symptoms/missed_period/book-causes-10a.htm
http://pedsinreview.aappublications.org/cgi/reprint/18/1/17?maxtoshow=&hits=1
0&RESULTFORMAT=&fulltext=menstrual+disorders&searchid=1&FIRSTINDEX=0&so
rtspec=relevance&resourcetype=HWCIT
http://pedsinreview.aappublications.org/cgi/reprint/13/3/83?maxtoshow=&hits=1
0&RESULTFORMAT=&fulltext=menstrual+disorders&searchid=1&FIRSTINDEX=0&so
rtspec=relevance&resourcetype=HWCIT
http://courses.washington.edu/conj/bess/reproductive/pcos2.png
http://img.medscape.com/article/720/869/720869-box2.jpg
http://www.theberries.ca/archives/dub1.html
http://www.medicine4faith.net/wp-content/uploads/2010/08/ovarCon.jpg