Monday, August 8th, 2011
 Normal
cycle lasts:
• 26 to 30 days, but may vary from 21 to 35 days
 Normal
menstrual flow lasts:
• 3 to 7 days
• A period lasting longer than 10 days is
considered pathologic
 Average
amount of blood loss per cycle:
• 30 to 40ml
• More than 80ml is considered pathologic
 Terms:
• Menorrhagia
 Heavy (>80ml) or prolonged bleeding (>7 days) that
occurs at regular cyclic intervals
• Metorrhagia
 Irregular vaginal bleeding (acyclic)
• Menometorrhagia
 Heavy vaginal bleeding occurring at irregular intervals
• Polymenorrhea
 Frequent vaginal bleeding at intervals more often than
every 21 days
 “Abnormal
vaginal bleeding”= all cases
of irregular, heavy, or frequent bleeding
 “Dysfunctional
uterine bleeding” =
bleeding that is not due to underlying
anatomic abnormalities or systemic
conditions
• *Most frequently caused by chronic anovulation
and immaturity of the hypothal-pit-ovarian axis
• Diagnosis of exclusion
 Most
common is anovulatory bleeding due
to immature hypothal-pituitary-ovarian axis
(DUB)
 Anovulatory bleeding is the most common
cause of acyclic bleeding and may be
associated with:
• Sports
• Stress
• Disordered eating
• Endocrinopahties (thyroid problems, DM, Cushings)
 May
suggest bleeding disorders or
uterine pathology
 The most common bleeding disorders
are:
• Thrombocytopenia (usually ITP)
• von Willebrand disease (occurs in 95% of
women)
 Usually a history of heavy bleeding from first
menstrual period
 vWf
– role in hemostasis by binding to
platelets and endothelial components;
carrier protein for Factor 8
 Presents with easy bruising, skin
bleeding, prolonged bleeding from
mucosal surfaces (ex: OP, GI, uterine)
• Nose bleeds >10 minutes
• Bleeds after tooth extraction
 Varies
from subtle onset of fatigue due to
iron deficiency anemia to acute mental
status changes or syncope caused by
severe blood loss (like our patient!)
 Menarche
 Usual pattern of bleeding
• Frequency and duration of menses
 Presence of menstrual cramping
 LMP
 Sexual history
• Any STDs
 ROS
• Symptoms of PCOS, thyroid disease, bleeding
disorders, hypothalamic amenorrhea
 Depo
 OCPs
 IUDs
 Psychotropic
medications
• Risperidone
 Illicit
drugs
 Herbs
 Dietary supplements
 Vital
signs
• Include orthostatic measurements
 Look
for signs of conditions in your DDx:
• PCOS
• Thyroid
• Bruising or petechiae
 Consider
bimanual and pelvic exam
• Pelvic U/S in those who can’t tolerate and exam
 CBC
 UPT
 PT
(exclude pregnancy in everyone!!)
 PTT
 von Willebrand panel
• Should be drawn before hormonal therapies start
because estrogen increases concentration
 Platelet
function assay
 GC/Chlamydia (in sexually active)
 TSH
 Testosterone, DHEAS (if suspect PCOS)
 Perimenarchal
DUB requires only
reassurance and iron therapy
 NSAIDS can help reduce blood loss
 Combination oral contraceptives
• Bleeding usually decreases significantly with 24 to
36 hours of hormonal therapy
• Estrogen = promotes clotting and causes
endometrial proliferation
• Progestin = stabilized the endometrial lining
 *Surgery
is rarely necessary (endometrial
ablation, hysterectomy)
 Kids: 3-6
mg elemental Fe/kg/day
 Adults: 60-100mg elemental Fe BID
 Less GI irritation when given with or after
meals
 Vitamin C may enhance absorption
 Antacids may decrease absorption
 Hgb should rise after 1-2 weeks of
treatment
 Hgb should return to normal at 6-8 weeks
 Tx for 6 months
Immunizations, Dr. Begue