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.)
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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.)
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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
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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
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Headache
Breast pain
Bloating
Irritability
Fatigue
Crying
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Abd pain
Clumsiness
Sleep alteration
Labile mood
Social withdrawal
Libido change
Appetite change
Requisite Symptoms
for PMDD Diagnosis
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Depressed mood
Anxiety/tension
Mood swings
Irritability
Decreased interest
Concentration
difficulties
Fatigue
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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
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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
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Infection
– Cervicitis—leads to bleeding from the cervix
– Endometritis—leads to sloughing off of
endometrial blood and mucous
Anatomic causes
(cont.)
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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)
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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
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Prolonged, heavy bleeding, can cause
anemia
– (which type?)
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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
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Fibroid Tx - Surgical
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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

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Recent breast exam or breast stimulation
Recent pelvic exam
Anovulation: POF
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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
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Any medication that affects the
cytochrome P-450 cycle, eg
psychotropic drugs
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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
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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
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Non-uterine causes
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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
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Genital trauma/foreign objects
Rectal bleeding or urinary tract source
Evaluation
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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.)
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Physical Exam
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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
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All patients:
– Pregnancy test
– CBC with platelets
– Recent Pap
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Over 35 yrs:
– Endometrial sample
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Documented drop in
hgb <10
– PT, PTT
– Bleeding time
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As indicated:
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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
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Hospitalize for low hgb (<7), and
strongly consider blood dyscrasia,
submucosal fibroid, or malignancy
Acute Bleeding: Control
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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
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Cycle with low dose OCP, patch, or vaginal
ring
Cycle with a progestin, eg Prometrium
Use of progestin-containing IUD (Mirena)
Choice depends upon:
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Contraceptive need
Smoking status
Medical history
Patient preference
Long Term Control
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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
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Uterine thermal balloon
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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
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This is a SURGICAL diagnosis
Characteristic diagnostic surgical gross
appearance
Small petechial lesions to larger “powder
burn” lesions 5-10 mm
– Multiple lesions
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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
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Physical
Tender nodules in posterior fornix
 Pain with uterine motion
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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
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Endometriosis Tx
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Take into account:
– Desire for fertility
– Age
– Symptoms
– Stage of disease
Tx
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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
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– Although extensive surgery can come
close
– Conservative surgery has 10-35%
recurrence
Amenorrhea
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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
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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
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Sterility: intrinsic inability to conceive
Fecundity: probability of achieving live
birth from one menstrual cycle
– Fecundability- likelihood of conception per
month
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Very few infertile patients are sterile (1-2%)
Epi
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13% of women (range 7-28%, age
dependant)
Incidence of primary and secondary
infertility increasing
– Why?

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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
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History
– Prior paternity
– Congenital abnormalities or undescended testes
– Prev surgery or infections
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PE
– Varicocele (MC cause)
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Semen analysis
– Sperm count
– Motility
– Morphology
Chicas
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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