Menstrual Disorders

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

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

Amenorrhea

Hypothalamic

Dysfunction Pituitary Dysfunction Ovarian Failure Anatomic Abnormalities of the Reproductive Tract

Hypothalamic Disorders
Low FSH, LH Congenital syndromes Systemic stresses

significant weight loss

anorexia bulimia

excessive exercise severe emotional distress

Hypothalamic Disorders

Destructive lesions or neoplastic lesions of the hypothalamus

increased serum prolactin level

Infiltrative or infective disorders

sarcoidosis encephalitis

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

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

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

Anatomic Abnormalities

Incomplete mullerian development

obstruction of outflow tract
imperforate hymen transverse vaginal septum atresia of the cervix

endometriosis frequently found also

Asherman syndrome

Other Causes of primary amenorrhea with no puberty

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

Diagnosis of Amenorrhea
Pregnancy Test Progestin Challenge See handout

Abnormal Uterine Bleeding

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

Terminology of Abnormal Bleeding

Oligomenorrhea = bleeding at intervals > 40 days that usually is irregular Polymenorrhea = bleeding at intervals < 22 days 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

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

Pre-puberty Bleeding
Premenarcheal- bleeding occurs prior to puberty- ABNORMAL Differential Diagnosis:

Trauma Cx or vag Ca Foreign body Exogenous estrogen Sporadic gonadotropin surge

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

Differential Diag of premenarchal bleeding

Precocious Puberty
Adrenal Hyperplasia Hypothyroidism Idiopathic

GI or GU tract bleeding

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

Organic Pathology Causing Bleeding in Repro Yrs

Polyp - Cx or endometrial Leiomyoma Adenomyosis Infection - cervicitis, endometritis Endocrine dysfunction

Pituitary/hypothalamus Adrenal Thyroid

Organic Pathology Causing Bleeding in Repro Yrs

Iatrogenic
IUD Drug use
hormones nonhormonal- effects dopamine metab (phenothiazines,TCAs,reserpine, alphamethyldopa)

Blood dyscrasias

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

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 dehydroepiandrosterone (DHEA)

Anovulatory Bleeding

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

Ovulatory DUB
Endometritis - tender uterus - tx with antibiotics Endometrial biopsy, cultures

presence of plasma cells within the endometrial glands and stroma

Ovulatory DUB
If endometritis is ruled out think Anatomic abnormalities of the

myometrium endometrium endocervix

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

Evaluation of Abnormal Bleeding

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

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 34 doses) Surgical hysteroscopy Endometrial ablation

Treatment contd
GnRH agonist (Lupron) Hysterectomy Laparotomy with myomectomy

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!

Causes of Postmenopausal bleeding

Neoplasm
Endometrial, vulva, vaginal, cx, tubes, ovary

Endometrial hyperplasia Polyp Estrogen - exogenous

endogenous(adipose tissue or neoplasm)

Trauma - vagina

endometrial cavity is opened to reveal lush fronds of hyperplastic endometrium

Causes of Postmenopausal bleeding

Infection
endometritis vaginitis (atrophic)

Vulvar dystrophy Idiopathic Non-genital tract

urinary or GI tract

Treatment of Postmenopausal Bldg

Endometrial biopsy D&C TAH