Disorders of the menstrual cycle
Barbora Kubesova
Abnormal Vaginal Bleeding
 Bleeding at an unexpected time
 Not bleeding often enough
 Bleeding too often
 Bleeding in an unexpected amount
 Too little or too much
 Causes
 Hormonal
 Anatomical (patholo
Normal Menstrual Flow
 Interval
 21-35 days
 28 day cycle women aged
 20-30
 Duration
 3-7 days
 Amount
 30-60cc
 More than 80 cc excessive
Median Menstrual Index
 Menstrual Index
 Menarche/
 cycle length/
 flow duration
 Median of czech women
 10 (years of age)/
 28 (days)/
 5 (days in length)
Basic Facts
 Ovarian Cycle
 Follicular phase (varies)
 Luteal phase
 (14 days)
 Endometrium cycle
 Menstruation
 Proliferation
 Secretory
Physiology of the menstrual cycle
 Coordinated hormonal control of the endometrium leading
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to pregnancy or regular shedding /periods/
HPO axis – hypothalamus-pituitary-ovarium
peptide hormones H-P direct ovary to produce steroid
hormones – control the endometrium
Complex process
Average age of menarché -13, menopause 52
LMP – day 1 of bleeding
Secondary amenorhoe - causes
 Secondary Amenorrhea
 Previously normal menstrual cycles
 Absence of menses for 6 months
 Or for a length of time = 3 previous cycles
 Multiple causes
 Hormonal
 Anatomical
Secondary amenorhoe - causes
 Secondary Amenorrhea
 Common non-pathological causes
 Pregnancy
 Lactation
 Hormonal contraception
 Menopause
 Always rule out pregnancy
Secondary Amenorrhea
 Recent Surgery Assess Anatomic Anomalies
 Asherman’s syndrome
 Destruction of endometrium
 Surgery, pregnancy,
 Infection
 No cramps
 Cervical stenosis
 History of cervical surgery
Secondary Amenorrhea
 Hypothalamic Dysfunction
 Decreased or Normal
 Anorexia nervosa
 Excessive exercise
 Stress
 Hypothalamic lesion
 Drugs/medications
FSH/LH
Secondary Amenorrhea
 Pituitary Dysfunction
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FSH/LH
Pituitary dysfunction often result of prolactin
Hyperprolactinemia
Hypothyroid
TRH elevated prolactin
Drugs (CNS)
Pituitary adenoma
Pituitary anatomical pathology rare
Sheheen’s syndrome
Overt Hyperprolactinemia
 Galactorrhea
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Prolactin
FSH/LH
Multiple duct, milky nipple discharge
Cause
Increased prolactin
Etiology
Physiologic
Excessive breast manipulation
Pharmacologic –Phenothiazines,
Antihypertensive,Antidepressants, Amphetamines
Oral contraceptives
Marijuana
Secondary Amenorrhea
 Ovarian Dysfunction
FSH/LH
 Premature ovarian failure
 40 years or less
 Post irradiation or chemotherapy
 Polycystic ovarian syndrome common cause
 Polycystic Appearing Ovary
Evaluation of Secondary Amenorrhea
History
 Menstrual history
 Contraception
 Pregnancy
 Surgeries
 Medications
 Weight changes
 Chronic diseases
Evaluation of Secondary Amenorrhea
Social History
 Drug abuse
 Stress
 Diet
 Sexual activity
Evaluation of Secondary Amenorrhea
Family History
 Thyroid
 Type II diabetes
 Cancer
 Mother’s age at menopause
 Evaluation of Secondary Amenorrhea Physical
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Examination
BMI
Hair distribution
Skin
Thyroid
Breasts
Discharge?
Abdomen
Masses? Tenderness?
 Diagnostic Strategies for Secondary Amenorrhea
 Rule out:
 Pregnancy
 Hormonal contraception
 Rule out:
 Medications
 Include social
 substance use and complimentary therapies
 Diagnostic Strategies for SecondaryAmenorrhea
 Rule out:
 Anorexia-bulimia-athlete
 Determine BMI
 Exercise/diet patterns
 Rule out:
 Obvious anatomical causes
 Pelvic examination
 Diagnostic Strategies for Secondary Amenorrhea
 Consider:
 1. TSH
 2. Prolactin
 Determine: “Can she make estrogen now?”
 Normal pelvic exam?
 Perform progesterone challenge
 MPA 10-30 mg 5-10 days
 If she bleeds polycystic ovarian syndrome
 No bleeding after progesterone challenge:
 Obtain FSH
 Elevated FSH:
 Ovarian failure
 Order TSH, ANA
 Normal FSH:
 Anatomical problems?
 eassess history of
 recent surgery
 No bleeding after progesterone challenge:
 Low FSH
 Pituitary problems
 Hypothalamic problems
 Order TSH and prolactin
 CNS symptoms or prolactin
 Referral for CT or MRI
 Reassess anorexia, bulimia,
 low body fat
 Reassess medications or
 breast stimulation
 No bleeding after progesterone challenge:
 Low FSH and Galactorrhea
 Assess discharge
 Spontaneous milky
 Unilateral or bilateral
 No associated mass
 Irregular menses
 S/S of pituitary tumor
 Headaches
 Visual changes
 Symptoms of underlying condition
 No bleeding after progesterone challenge:
 Low FSH and Galactorrhea
 Diagnostic Tests
 Serum prolactin
 MRI
 Prolactin level hogher100
 TSH
 Other tests per underlying conditions
 No bleeding after progesterone challenge:
 Low FSH and Galactorrhea
 Diagnostic Tests
 Serum prolactin
 CAT or MRI
 Prolactin level higher than100
 TSH
 Other tests for underlying conditions
 No bleeding after progesterone challenge:
 Normal FSH
 Consider anatomical problems
 History of recent surgery?
 Administer package of OCPs or estradiol followed by
 MPA
 No bleeding?
 Asherman’s syndrome
 Cervical stenosis
 Treatment for Hypothalamic Amenorrhea
 Diet, exercise, stress management
 Medication change
 Osteoporosis
 Assessment
 Treatment
 Consider oral
 contraceptive pills
 Counseling referral
 Treatment for Galactorrhea
 Precipitating factors
 Discontinue when identified
 Eliminate drugs when reasonable
 Treat underlying causes
 Hypothyroidism
 Bromocriptine or other dopamine agonist
 If normal prolactin and regular menses
 May manage expectantly
 Periodic prolactin levels
 Polycystic Ovarian Syndrome Treatment
 Combined OCP
 Regulate menses
 Prevent endometrial hyperplasia
 Treat acne
 Cosmetic therapy
 Acne
 Hirsutism
 Abnormal Vaginal Bleeding
 Developmental Classifications
 Childhood
 Adolescence
 Reproductive
 Perimenopause
 Menopause
 Abnormal Bleeding in Adolescent
 Dysfunctional uterine
 Bleeding
 Irregular ovulation
 Diagnosis of exclusion
 Hormonal contraception
 Vulvovaginal
 Abnormal Bleeding in Perimenopause
 Dysfunctional uterine
 Bleeding
 Diagnosis of exclusion
 Benign neoplasms
 Endometrial polyps
 Degenerating
 submucosal fibroids
 Endometrial cancer
 Endometrial polyps
 Abnormal Bleeding in Perimenopause
 Exogenous hormone
 (HRT/ERT)
 Bleeding from other organs
 Urethra, bladder, bowel
 Vulvovaginal atrophy
 Trauma
 Infection
 Abnormal Bleeding in Menopause
 Cancer until proven
 otherwise
 Atrophic changes
 Bleeding from other organs
 Urethra
 Bladder
 Bowel
Menorrhagia
 Prolonged excessive bleeding at regular intervals
 >7 days of bleeding and/or
 >80 ml of uterine bleeding
 Regular, predictable, cyclic, cramp
 Causes of Menorrhagia
 Fibroids
 Adenomyosis
 Prostaglandin imbalance
 Non-hormonal IUD
 Clotting disorders
 Submucosal
Metrorrhagia
 Bleeding at irregular, but frequent intervals
 Amount is variable
 Unpredictable, often painless
 Irregular, irregularity
 Causes of Metrorrhagia
 Dysfunctional uterine bleeding
 Polycystic ovarian syndrome
 Endometrial cancer
 Progesterone
 contraceptive
Menometrorrhagia
 Prolonged bleeding occurring at irregular intervals both
between and during menses
 Caused by combinations of above pathologies
Intermenstrual Bleeding
 Bleeding of variable amounts
 between menstrual periods
 Causes
 Combined hormonalcontraceptives
 Progesterone contraception
 HRT
 Endometritis
 Chlamydias
Postcoital Bleeding
 Bleeding following coitus or cervical manipulation
 Cervicitis
 Trichomonas
 Gonorrhea
 Chlamydia
 Herpes
 Cervical cancer
 Cervical polyp
Polymenorrhea
 Uterine bleeding occurring
 at regular intervals less than 21 days
 Causes:
 Short follicular phase
 Inadequate luteal phase
 Dysfunctional uterine bleeding
Oligomenorrhea
 Infrequent uterine
 bleeding with menstrual intervals greater than 35 days
 Causes:
 Menopause
 Adolescence
 OCP manipulation
 Hypothalamic dysfunction
 Chronic illness
 Polycstic ovary
Hypomenorrhea
 Unusually light flow at
 regular intervals
 Causes
 Oral contraceptive pills
 Hormonal contraception
 Gynecological Etiologies of Abnormal Bleeding
 Vulva/vaginal
 Trauma
 Infection
 Atrophy
 Cancer
Gynecological Etiologies of
Abnormal Bleeding
 Cervix
 Infection
 Polyps
 Cancer
Gynecological Etiologies of
Abnormal Bleeding
 Uterus
 Infection
 Hyperplasia
 Cancer
 Endometrial polyps
 Leiomyomas
 Adenomyosis
Gynecological Etiologies of
Abnormal Bleeding
 Ovaries
 Cancer
 Functional cysts
Management of Abnormal Bleeding
Dysfunctional Uterine Bleeding
 Hormonal contraception
 Cyclic progestin
 Treat anemia
 NSAIDs
 May need estrogen to build endometrium
 Refer for surgery/ablation
 ALWAYS rule out
 endometrial cancer in perimenopausal woman
Leiomyomas
 Classification of Leiomyomas
 Interstitial or intramural
 Within uterine wall
 Submucosal
 Protrude into uterus
 Subserosal
 Protrude through outer uterine wall
 Pedunculated
 Pedicle attached to uterus
Leiomyomas
 Firm, irregular, non-tender
 uterus
 May palpate firm mass
 Ultrasound
 Treat symptoms
 If no improvement
 May refer for surgery
 GnRH agonists prior to shrink fibroids
Adenomyosis
 Multiparous women
 Over age 30
 Menorrhagia
 Dysmenorrhea
 Smooth 􀈹 tender uterus
 More pain during menses
 Treat symptoms
 Tricycle OCPS
 Refer for surgery
Diagnostic Strategies for
Abnormal Bleeding
 Pelvic
 Start from the external genitals and work your way in for
causes of abnormal bleeding
 Laboratory Strategies forAbnormal Bleeding
 Depend on presentation
 Sensitive pregnancy test
 Ultrasound
 Pap smear
 Cultures for GC/CT
 CBC, PT/PTT
 Menopausal women
 Endometrial biopsy
Primary Dysmenorrhea
 Etiology
 No pelvic pathology
 Prostaglandin induced cramping
 Treatment
 NSAIDS
 Contraception that inhibits ovulation
 Combined oral contraceptive pills
 Depo-Provera
 Causes of Secondary Dysmenorrhea
 Non-progesterone IUD
 Endometriosis
 Pelvic inflammatory disease
 Cervical stenosis
 Degenerating fibroids
PMS
 What is PMS?
 Affects 30-40% of women of childbearing age
 Symptoms occur in luteal phase
 Symptoms of PMS
 Over 150 documented
 Relieved when menses occurs
 Present for at least 3 consecutive cycles
PMS
 Who Gets PMS?
 anyone who is menstruating
 i.e. from puberty to menopause
 Most common risk factors for PMS:
 30 + years old
 Experiencing emotional stress
 Difficulty maintaining stable weight
 History depression/anxiety
 Other family members experience PMS
PMS
 Common PMS Symptoms
 Mood swings
 Irritability
 Anxiety
 Depression
 Weight gain
 Headaches
 Joint and muscle aches
PMS
 Common PMS Symptoms
 Backaches
 Changes in sex drive
 Food cravings
 Water retention
PMS
 Criteria for PMS Symptoms
 Occur in the luteal phase of cycle
 Increase in severity as cycle progresses
 Resolve with start of menses or shortlyafterwards
 Are present for at least 3 consecutive cycles
 Does NOT have to meet minimum of 5symptoms like
PMDD
PMS
 Causes of PMS
 No one exact cause has been proven
 Too much estrogen?
 Too little progesterone?
 Too little Vitamin B6?
 Too little serotonin?
 Too much prolactin?
 Change in glucose metabolism?
PMS
 Treatments
 NSAIDs may improve dysmenorrhea
 Exercise and diet
 Calcium effective in a few trials (1500 mg/day)
 Serotonin uptake release inhibitors
 Prozac (fluoxitine) or Xanax
 Effective in repeated clinical trials
 Other antidepressants are not effective
 Low-dose potassium sparing diuretic
 Sprinolactone
PMS
 Diagnosis of PMS
 No blood test is diagnostic
 PMS diary or chart for 3 months.
 Listen to the woman
 Rule out other diagnoses