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Menstrual disorders

Menstrual disorders. Menstrual disorders. Abnormal uterine bleeding/ Heavy uterine bleeding Amenorrhea Primary and Secondary Dysmenorrhea, Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD). ABNORMAL UTERINE BLEEDING. Abnormal Uterine Bleeding.

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Menstrual disorders

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  1. Menstrual disorders Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  2. Menstrual disorders Abnormal uterine bleeding/ Heavy uterine bleeding Amenorrhea Primary and Secondary Dysmenorrhea, Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD) Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  3. ABNORMAL UTERINE BLEEDING Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  4. Abnormal Uterine Bleeding • defined as changes in frequency of menses, duration of flow or amount of blood loss Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  5. Definition of terms • Mean interval between menses is 28 days (±7 days) • Mean duration of menstrual flow is 4 days (>7 days is menorrhagia) • Mean amount of MBL in normal women is about 35 mL (>80 mL is menorrhagia) Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  6. DEFINITION OF MENSTRUAL CYCLE IRREGULARITIES: NO LONGER USED

  7. Etiology • Two major categories A. Organic I. Systemic II. Reproductive Tract disease B. Dysfunctional I. Anovulatory II. Ovulatory Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  8. A. Organic: Systemic Disease • Chronic systemic diseases e.g. hepatitis, renal disease, cardiac disease, and coronary vascular disorders (usually from anovualtion due to hypothalamic cause or problem with estrogen metabolism) • Disorders of blood coagulatione.g. von Willebrand's disease and prothrombindeficiency • Disorders producing platelet deficiency e.g leukemia, severe sepsis, idiopathic thrombocytopenic purpura (ITP), and hypersplenism • Drugse.g.anticoagulants • Endocrine disorders e.g. hormonal disorders involving thyroid, PRL, and cortisol Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  9. A. Organic: Reproductive Tract Disease • The most common cause: accidents of pregnancy • Other causes: 1) Malignancy of the genital tract endometrial and cervical cancer – most common vaginal, vulvar, fallopian tube cancer – less common 2) Anatomic uterine abnormalities submucous myomas, endometrial polyps, adenomyosis (probably d/t abnormal vasculature and blood flow and increased inflammatory changes) 3) Cervical lesions erosions, polyps, cervicitis (postcoital bleeding) Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  10. ABNORMAL UTERINE BLEEDING: WORKUP • History • Timing of bleeding, quantity of bleeding, menstrual hx including menarche and recent periods, associated sxs, family hx of bleeding disorders • Physical • Speculum exam to R/o vaginal or cervical source of bleeding • Bimanual exam may reveal bulky uterus/discrete fibroids • Assess for obesity, hirsutism, stigmata of thyroid disease (hypothyroidism associated with anovulation), signs of hyperprolactinemia (visual field testing, galactorrhea) • Pap smear • Endometrial biopsy, if appropriate • Pregnancy Test • Imaging • Pelvic ultrasound • Sonohystogram(SIS) or hysterosalpingogram (HSG) • Surgical • Endometrial biopsy (>35 y/o, long history of excessive bleeding, EM >8mm) • Hysteroscopy • D & C Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  11. AUB: TREATMENT STRATEGIES • Medical vs Surgical • Depends on the ff. patient characteristic: age, desire to preserve fertility, coexisting medical conditions, and patient preference • Anovulatory DUB • For adolescents: Cyclic progestogen(MPA 10mg OD for10 days/month x 6 mos) – 1st line COCs – only 2nd line used if DUB persists beyond 6 mos. on cyclic progestogen, because it does not allow HPO to mature • For perimenopausal women: Low dose COCs (20ug EE)– 1stline Cyclic progestogen– only 2ndline, this will help the endometrium but not reliably control bleeding because of unpredictability of the hormonal situation Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  12. AUB: TREATMENT STRATEGIES • Ovulatory DUB Cyclic progestogen(MPA 10mg OD for 3 weeks/mo.) – shorter duration do not work Local progesterone exposure (LNG-IUS) – 80% MBL by 3 mos(lasts >5 yrs) NSAIDs– Mefenamic acid 500mg TID, Ibuprofen 400mg TID, Meclofenamate Na 100mg TID, Naproxen Na 550mg LD then 275mg q6 Antifibrinolytic agents–50% MBL EACA (ε-aminocaproic acid)18g/d x 3 days then 12g ,9g ,6g, 3g = total 48g AMCA (tranexamic acid) 6/d x 3 days then 4g, 3g, 2g, 1g,= total 22g PAMBA (para-amino methylbenzoic acid) COCs – 50% MBL Androgenic steroids– Danazol 200-400mg/day x 12 weeks 60% MBL GnRH Agonists – given for 3 months, reserved for women with severe MBL with failed with other medication Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  13. AUB: TREATMENT STRATEGIES • Acute Bleeding Pharmacologic Agents vs. Surgical Therapy Dilatation and curettage – fastest way, best when EM is thick >10-12 mm and px is >35 y/o Estrogens – best when EM is thin <5mm Oral CEE 10mg/day in 4 divided doses IV CEE 25mg q4-6 hrs. High dose OCPs(50ug EE) 4tabs OD, continued for 1week after bleeding stops Progestogens– no evidence in stopping acute bleeding, and can only be used after stabilization of the endometrium (after 2-3 days of estrogen) MPA 10mg/day x 10 days/month Norethindrone acetate 2.5-5mg/day in 4 divided doses Endometrial ablation – used if medical therapy is not effective 22-55% amenorrhea success rate 86-99% satisfaction rate only 25% proceed to hysterectomy w/in 4 years Hysterectomy– used to treat persistent ovulatory DUB when medical therapy has failed Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  14. The “MOST COMMON”

  15. Heavy Menstrual Bleeding Fraser. International definitions of abnormal menstrual bleeding. FertilSteril 2007 & Hum Reprod 2007

  16. Abnormal Uterine Bleeding • Chronic AUB • bleeding from the uterine corpus that is abnormal in volume, regularity, and/or timing that has been present for the majority of the last 6 months • Acute AUB • episode of heavy bleeding that, in the opinion of the clinician, is of sufficient severity to require immediate intervention to prevent further blood loss

  17. Abnormal Uterine Bleeding • Intermenstrual bleeding (IMB) • occurs between clearly defined cyclic and predictable menses and includes both randomly occurring episodes as well as those that manifest predictably at the same time in each cycle • Breakthrough bleeding (BTB) • unscheduled bleeding that occurs during the use of exogenous gonadal steroid therapy

  18. Causes of Heavy Menstrual Bleeding • PALM group • discrete structural abnormalities that can be seen and measured by imaging techniques such as ultrasound or hysteroscopy • COEIN group • non-structural entities, not defined by imaging or histopathology

  19. Causes of Heavy Menstrual Bleeding • Polyp • Adenomyosis • Leiomyoma • Malignancy/Hyperplasia PALM COEIN • Coagulopathy • Ovulatory Disorders • Endometrial Disorders • Iatrogenic Causes • Not Classified *FIGO classification system for causes of abnormal uterine bleeding in the reproductive years

  20. AUB-P PALM

  21. AUB-A PALM

  22. PALM AUB-LSM

  23. Leiomyoma Subclassification System

  24. PALM AUB-M

  25. COEIN AUB-C

  26. COEIN AUB-O

  27. COEIN AUB-O

  28. COEIN AUB-E

  29. COEIN AUB-I

  30. COEIN AUB-N

  31. How could this system be used? • Polyp • Adenomyosis • Leiomyoma • Malignancy/Hyperplasia PALM COEIN • Coagulopathy • Ovulatory Disorders • Endometrial Disorders • Iatrogenic Causes • Not Classified

  32. Management of Heavy Menstrual Bleeding • Heavy menstrual bleeding (HMB) • volume of monthly blood loss of more than 80 ml • management may be either medical or surgical

  33. Management of Heavy Menstrual Bleeding

  34. AMENORRHEA Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  35. Amenorrhea • May be physiologic or pathologic which may include primary and secondary causes • Primary amenorrhea. No menses by age 14 in the absence of growth or development of secondary sexual characteristics. Or No menses by age 16 with the appearance of secondary sexual characteristics. • Secondary amenorrhea. In a menstruating women, the absence of menstruation for three previous cycle intervals or 6 months. Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  36. Evaluation of Amenorrhea History Physical examination Diagnostics

  37. Diagnostic Evaluation for Secondary Amenorrhea

  38. Causes of Amenorrhea Primary Amenorrhea Secondary Amenorrhea

  39. Primary causes initially classified on whether absent uterus and/or breast development are also found

  40. Amenorrhea Primary causes initially classified on whether absent uterus and/or breast development are also found Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  41. Amenorrhea • Secondary amenorrhea may be physiologic or pathologic. Pathologic lesions include intra-uterine adhesions after curettage. Work up include: HYPOTHALAMIC CAUSES, PITUITARY, OVARIAN, UTERINE OR OUTFLOW TRACT PROBLEMS Lentz GM, Lobo RA, Gershenson DM, and Katz VL. Comprehensive Gynecology 2012. 6th Edition.

  42. Compartmental Systems • Compartment I • Disorders of the outflow tract • Compartment II • Disorders of the ovary • Compartment III • Disorders of the anterior pituitary • Compartment IV • Disorders of CNS (hypothalamic factors)

  43. Compartment I: Disorders of the Outflow Tract or Uterus • Mullerian Anomalies • Imperforate hymen • Transverse vaginal septum • Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome) • Androgen insensitivity • Ashermans syndrome

  44. Imperforate Hymen • The hymen itself is formed from the proliferation of the sinovaginal bulbs, becoming perforate before or shortly after birth. • Results when this sheet of tissue fails to completely canalize • Translucent thin membrane just inferior to the urethral meatus that bulges with valsalva maneuver

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