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Menstrual Disorders
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Objectives

 To understand the physiology of the normal menstrual

cycle
 To know definition and types of abnormal uterine
bleeding
 How to approach a case of abnormal uterine bleeding
 Amenorrhea; types and causes
 Dysmenorrhea; types and management
 When to refer to secondary care
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Introduction

 Menstrual disorders and abnormal uterine bleeding

(AUB) are among the most frequent gynecologic
complaints. [1]

 Menstrual disorders frequently affect the quality of life

of adolescents and young adult women and can be
indicators of serious underlying problems.
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Normal Menstrual Cycle

 The normal menstrual cycle is a tightly coordinated

cycle of stimulatory and inhibitory effects that results in
the release of a single mature oocyte from a pool of
hundreds of thousands of primordial oocytes.
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H-P-O axis
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 The average adult menstrual cycle is 28 days, with a

range of 21 to 35 days , and lasts 3 to 7 days.
 The median blood loss during each menstrual period is
30 mL; the upper limit of normal is 80 mL.
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CASE 1
A 35-year-old female presents to your office with concerns
about heavy menstrual periods for the past year that
occur at irregular intervals. She explains that sometimes
her menses comes twice a month but other times will skip
2 months in a row. Her menses may last 7 to 10 days and
require 10 to 15 thick sanitary napkins on the heaviest
days. She admits to some fatigue, but she denies any
lightheadedness. She has no pain with menses or
intercourse. She denies any vaginal discharge or any other
symptoms. She is a nonsmoker. She has had normal Pap
smears in the past. She is in a stable monogamous
relationship with her husband and denies a history of
sexually transmitted infections (STIs). On physical
examination, her blood pressure is 120/80 mmHg and her
body mass index (BMI) is 32. Her physical examination is
normal, including pelvic exam.
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 The patient’s bleeding pattern is best described as …?

 The most likely diagnosis is …?
 What is the most likely underlying mechanism for

this patient’s abnormal bleeding?

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Abnormal Uterine Bleeding

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Definition
Abnormal uterine bleeding refers to uterine bleeding
outside of the parameters noted below :
Duration greater than 7days
Flow greater than 80 mL/cycle or subjective impression
of heavier-than-normal flow (ie, more than six full pads or
tampons per day)
Occur more frequently than every 21 days or less
frequently than every 35 days
Intermenstrual bleeding or postcoital spotting
Absence of menses
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 Oligomenorrhea: menstruation occurring with intervals of more
than 35 days

 Polymenorrhea: menstruation occurring regularly with intervals

of less than 21 days

 Metrorrhagia: menstrual bleeding occurring at irregular intervals

or bleeding between menstrual cycles

 Menorrhagia: regular menstrual cycles with excessive flow

(technically more than 80 mL of volume) or menstruation lasting
more than 7 days

 Menometrorrhagia: menstrual bleeding occurring at irregular

intervals with excessive flow or duration
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Prevalence and Impact
 In population-based studies, approximately 10 to 35
percent of women report having menorrhagia. [2-4]
 Menorrhagia is a common reason for referral to a
gynecologist .
 Iron deficiency anemia develops in 21 to 67 percent of
cases. [2]
 Excessive and irregular bleeding can affect the quality
of life. Absenteeism from work or school is bothersome
to many women and bleeding may also interfere with
sexual activity.
+Causes throughout Woman’s
Lifetime
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Anovulatory Uterine Bleeding

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Pathophysiology
 Estrogen breakthrough bleeding
Anovulatory cycles have no corpus luteal formation.
Progesterone is not produced. The endometrium continues
to proliferate under the influence of unopposed estrogen.

 Estrogen withdrawal bleeding

This frequently occurs in women approaching the end of
reproductive life. Ovarian follicles in these women secrete
less estradiol. Fluctuating estradiol levels might lead to
insufficient endometrial proliferation with irregular
menstrual shedding.
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Causes

 In Adolescents

Failure occurs secondary to delayed maturation of the

hypothalamic-pituitary axis. Normal in 1-2 years after
menarche.

 Peri-menopausal

Anovulatory bleeding in menopausal transition is related

to declining ovarian follicular function.
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 Approximately 6 to 10 percent of women with anovulation
have underlying polycystic ovary syndrome.

 Uncontrolled diabetes mellitus, hypo- or hyperthyroidism,

and hyperprolactinemia also may cause anovulation by
interfering with the hypothalamic-pituitary-ovarian axis.

 Antiepileptics (especially valproic acid [Depakene]) may

cause weight gain, hyperandrogenism, and anovulation.

 Use of typical antipsychotics (e.g., haloperidol), and some

atypical antipsychotics (e.g. risperidone [Risperdal]) may
contribute to anovulation by raising prolactin levels
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Evaluation

First, whom to evaluate ?

Patients with irregular cycles who should be evaluated

include

a)adolescentswith consistently more than three months

between cycles or

b)those with irregular cycles for more than three years [3];

c)women who are likely perimenopausal and have

increased volume or duration of bleeding over baseline.
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 Initial evaluation of anovulatory uterine bleeding should
include

a) Confirm a uterine source of bleeding on physical

examination

b) Perform a pregnancy test.

c) Assess whether the woman is pre- or postmenopausal.

d) Evaluate the pattern, volume, and duration of blood

loss.
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e) Assess ovulation:

• Ovulation can generally be documented clinically,

based on regular cyclic menses with molimina (eg,
breast tenderness, bloating or pelvic discomfort,
mood changes, thin vaginal discharge), or

• can be confirmed by a serum progesterone level

measured in the presumed luteal phase of the
menstrual cycle; in most laboratories, a level of >4
ng/dL confirms ovulation.

f) Perform laboratory testing for anemia

g) Perform pelvic sonography to assess for uterine or

other reproductive tract abnormalities that may
contribute to uterine bleeding.
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g) ACOG recommends endometrial tissue assessment to
rule out cancer in

i. in adolescents and in women younger than 35 years

with prolonged unopposed estrogen stimulation,

ii. women 35 years or older with suspected anovulatory

bleeding, and

iii. women unresponsive to medical therapy

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Ovulatory Uterine Bleeding

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 Ovulatory abnormal uterine bleeding, or menorrhagia,

presents as bleeding that occurs at normal, regular
intervals but that is excessive in volume or duration.
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Etiologies
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Bleeding disorders
Suspected if :

[Link] since menarche

[Link] history of bleeding disorders

[Link] history of 1 or more of the following:

• Notable bruising without known injury
• Bleeding of oral cavity or gastrointestinal tract without
obvious lesion
• Epistaxis greater than 10 minutes duration (possibly
necessitating packing or cautery.
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CASE 2

A 27-year-old nulligravida female presents to your office

for routine exam. Upon gynecological history, you
discover that she has a 5-year history of oligomenorrhea,
with only approximately two or three menses a year. She
denies intercycle spotting or premenstrual symptoms.
Her last menses was 3 months ago. Her blood pressure is
120/75 mmHg and her BMI is 34. Her physical exam
reveals a moderate amount of facial hair and facial acne.
Her pelvic examination is unremarkable
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 What condition do you suspect in this patient?

 What are the treatment options ?

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Amenorrhea
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Definition and types
 Primary amenorrhea is defined as the absence of
menses at:

i. age 16 in the presence of normal growth and

secondary sexual characteristics, or

ii. age 14, if no menses have occurred and there is an

absence of secondary sexual characteristics.

 Secondary amenorrhea is the absence of menses for

three months in women with previously normal
menstruation and for nine months in women with
previous oligomenorrhea.
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Primary Amenorrhea
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Etiology of 1ry Amenorrhea
Hypothalamic and Pituitary causes
①Functional hypothalamic amenorrhea.

•Abnormal hypothalamic gonadotropin-releasing hormone

(GnRH) secretion  decreased gonadotropin pulsations

①absent LH surges

②absence of normal follicular development

③anovulation.

④Multiple factors may contribute to the pathogenesis of

functional hypothalamic amenorrhea, including eating
disorders (such as anorexia nervosa), exercise, and
stress
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② Congenital GnRH deficiency or idiopathic
hypogonadotropic hypogonadism

③ Constitutional delay of puberty

• characterized by both delayed adrenarche and

gonadarche.

④ Hyperprolactinemia
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Ovarian Causes
①Gonadal dysgenesis

②Turner syndrome

③Polycystic ovary syndrome

④Premature ovarian failure

•Loss of ovarian function before age of 40

•Idiopathic, but maybe related to a variant gene.

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Polycystic Ovarian Syndrome
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Congenital disorders of the uterus and vagina

①Müllerianagenesis causes approximately 15 percent of

primary amenorrhea.[4]

②Imperforate hymen

③Transverse vaginal septum

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Diagnosis
History
Detailed history of pubertal development
Family history of menarche, pubertal development
History of weight loss, stress, exercise (athletic activity)
Detailed dietary history
History of contraception, medications
History suggestive of CNS disease (eg, headaches,
visual changes)
History of chronic illnesses (eg, Crohn disease)
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Physical examination
Height, weight, and growth charts
Breast development, pubic hair
Syndromic appearance (eg, short stature, webbed neck)
Visual fields, thorough neurologic examination, optic
fundi
Evidence of hyperandrogenism (eg, acne, hirsutism,
clitoromegaly)
Evidence of thyroid disease
Evidence of chronic illnesses
Evidence of pregnancy
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Evaluation

Primary amenorrhea is evaluated most efficiently by

focusing on the

a)presence or absence of breast development (a marker

of estrogen action and therefore function of the ovary),

b)the presence or absence of the uterus (as determined

by ultrasound, or in more complex cases by magnetic
resonance imaging)

c)and the follicle-stimulating hormone (FSH) level.

+Etiology of 2ry Amenorrhea
 PREGNANCY is the most common cause of
secondary amenorrhea.
 Hypothalamic dysfunction

① Functional hypothalamic amenorrhea

② Inflammatory or infiltrative diseases

([Link])

③ Brain tumors (i.e. Craniopharyngioma)

④ Cranial irradiation

⑤ Pituitary stalk dissection or compression

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 Pituitary dysfunction

① Hyperprolactinemia
• Prolactinomas account for 20% of secondary
amenorrhea
• Account for 90% of secondary amenorrhea due to
pituitary problems

② Pituitary tumors
• Acromegaly
• Corticotroph adenomas (i.e. Cushing’s disease)
• Meningioma (of the sella), germinoma, glioma

③ Empty sella syndrome

④ Pituitary infarct/pituitary apoplexy

• Sheehan’s syndrome
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 Ovarian dysfunction

•Menopause: defined as 12 months of amenorrhea in a

woman over age 45 in the absence of other biological
or physiological causes.

•Premature ovarian failure

•Surgical removal

•Polycystic ovarian disease

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Uterine causes

① Acquired scarring of the endometrium

• due to instrumentation e.g. Asherman’s Syndrome

• due to infection eg. tuberculosis

① Cervical stenosis, often due to instrumentation

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Prolactin >100 ng per mL (100 mcg per L)
Altered metabolism
Liver failure
Renal failure
Ectopic production
Bronchogenic (e.g., carcinoma)
Breastfeeding

Prolactin <100 ng per mL

Empty sella syndrome
Pituitary adenoma
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CASE 3

A 15-year-old nulligravida female presents with her

mother for evaluation of painful periods. Menarche was
at age 14. Her periods are typically every 4–8 weeks and
are very painful. She has missed 1–2 days of school with
each menses because of the severe pain and has been
suspended from the volleyball team because of missed
practices. She denies intercourse. She has never had a
pelvic examination. Her review of systems is otherwise
negative.
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 What is the MOST likely etiology of her

irregular cycles?
 What is the etiology?
 What is the best first-line treatment for this

patient?
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Dysmenorrhea
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Definition and types

 Dysmenorrhea is defined as difficult menstrual flow or

painful menstruation. It is one of the most common
gynecologic complaints in young women who present
to clinicians.[5]

 Dysmenorrhea can be divided into 2 broad categories:

primary (spasmodic) and secondary (congestive).
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Primary dysmenorrhea

 Primary dysmenorrhea is defined as menstrual pain that

is not associated with macroscopic pelvic pathology.

 It typically occurs in the first few years after

menarche[6]and affects as many as 50% of postpubertal
females.

 In an epidemiologic study of an adolescent population

(age range, 12-17 years), reported that dysmenorrhea
had a prevalence of 59.7%. [7]
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Risk factors
 Early age at menarche (< 12 years)
 Nulliparity
 Heavy or prolonged menstrual flow
 Smoking
 Positive family history
 Obesity
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Pathophysiology

 Current evidence suggests that the pathogenesis of

primary dysmenorrhea is due to prostaglandin F2α
(PGF2α), a potent myometrial stimulant and
vasoconstrictor, in the secretory endometrium. [8]
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Treatment
 Treatment is directed at providing relief from the
cramping pelvic pain and associated symptoms .

 Nonsteroidal anti-inflammatory drugs (NSAIDs) are the

best-established initial therapy for dysmenorrhea. [9]
They decrease menstrual pain by lowering
prostaglandin F2α (PGF2α) levels in menstrual fluid.

 Oral Contraceptives also relieve symptoms, particularly

if contraception is required.
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Secondary dysmenorrhea
 Less common than primary dysmenorrhea
 It is associated with pelvic pathology
 It tends to occur several years after the menarche
 The woman may complain of a change in the timing
and intensity of her pain
 The pain may last throughout menstruation
 The pain may be associated with discomfort before the
onset of menstruation.
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Causes

 Leiomyomata (fibroids)
 PID
 Tubo-ovarian abscess
 Endometriosis
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Management

 Treatment of secondary dysmenorrhea involves

correction of the underlying organic cause.

 Specific measures (medical or surgical) may be

required to treat pelvic pathologic conditions (eg,
endometriosis) and to ameliorate the associated
dysmenorrhea
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