Menstrual Cycle

Disorders

ANDI PRATAMA
TRIA ERLITA

Introduction
Menarche:
Median age: 12.7 yrs
African-american earlier than Caucasian
2-2.5yrs after breast development

Duration:
Between 21 and 35 days (mode: 28)
Lasting: 3-7days
Blood lost: 30-40ml

Definition
Menstrual cycle disorder or dysfunction

uterine bleeding is an abnormal menstrual

bleeding on prolonged cycle, mestruation,
and amount of bleeding.

Menstrual disorders on reproductive

period
Prolonged cycle and amount of

bleeding
- Hypermenorhe ( menorrhagia )
- Hypomenore
Menstrual cycle disorders
- Polymenorrhea
- oligomenorrhea
- Amenorrhea

Outside of the menstrual cycle

- Menometrorrhagia
On menstrual cycle
- Dismenorrhea
- PMS

Physiology

Ovary cycle

Ovary function control

Menstrual cycle disorder

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

Hypomenorrhea
Less menstrual bleeding or the menstrual
cycle less than normal.
Etiology: organic causes or endocrinology.
Polimenorrhea
Menstrual cycle <21 days
Etio : endocrinologic causes

Etiology of menstrual
disorder
- Myoma uteri
- polyp of endometrium
- hyperplasia of endometrium
- infection of cervix, endometrium, uterine
- Trauma
- Endometriosis
- Arterio-venous malformation of the
uterine
- hemostasis disorders
- endocrinologic problem

Amenorrhea
Classification:

With pubertal delay

2. With normal pubertal development
3. Genital abnormalities
4. Hyperandrogenic anovulation
1.

Amenorrhea
1. With pubertal delay
A. Hypergonadotropic

hypogonadism
OVARIAN FAILURE

Turner
XY gonadal dysgenesis
Autoinmmune oophoritis
Exposure to chemo or
RT(alkylating)
17 alpha hydroxylase
deficiency

Elevated FSH

Amenorrhea
1. With pubertal delay
B. Hypogonatropic hypogonadism
PITUITARY:
Adenoma
Prolactinoma
Craniopharyngioma
Hemochromatosis
Hypothyroidism
Breast stimulation
Phenothiazines, opiates
(-PRL inhibitor factor)

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

Low or normal
FSH

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:
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

Surgery

Secondary
amenorrhea
>100ng/m
l

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

5-10 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

Treatment of DUB
Acute
bleeding and
excessive
bleeding

- Estrogen

progestin
Combinatio
n
- Estrogen
- Progestin

Dilatation &
curetage

Irreguler
bleeding
- Estrogen
progestin
Combination
- Progestin
- Ablation
endometrium
- Resectio
histerescopi
dan
histerectomy

Menorrhagi
a
- estrogen
progestin
Combination
- Progestin
- NSAID
- IUD with
Levonorgestre
l

DYSMENORRHEA

Dysmenorrhea
(painful menses)
Primary:
Secondary:
Decrease of progesterone
levels al end of luteal
Associated with pelvic
phase: lysosomal
pathology:
membranes are unstable
Endometriosis
release enzymes formation:
Miomas
Prostaglandins
PID
Keep increasing during luteal
and menstrual phases
STD
Uterine hypercontractibility
Genital tract obstruction
Tissue ischemia
Nerve hypersensitivity
(Later age, Menorrhagia,
(just before or 1st days of
Dyspareunia, Pain with
menses)
defecation, worsening with
every cycle or mid-cycle,
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

References
http://pedsinreview.aappublications.org

/cgi/reprint/13/2/43?maxtoshow=&hits=10
&RESULTFORMAT=&fulltext=menstrual+disor
ders&searchid=1&FIRSTINDEX=0&sortspec=r
elevance&resourcetype=HWCIT
http://www.aafp.org/afp/2006/0415/p1374.h
tml
http://www.wrongdiagnosis.com/symptoms/
missed_period/book-causes-10a.htm
http://pedsinreview.aappublications.org
/cgi/reprint/18/1/17?maxtoshow=&hits=10
&RESULTFORMAT=&fulltext=menstrual+disor
ders&searchid=1&FIRSTINDEX=0&sortspec=r
elevance&resourcetype=HWCIT