Menstrual Disorder

Definition
Menstrual disorders or also called
abnormal uterine bleeding is abnormal
menstrual bleeding in terms of cycle
length, duration and amount of menstrual
bleeding.

Onset of menarche
The mean interval between breast
budding and menarche is 2-3 years.
The absence of breast budding is
indicative of a lack of estradiol synthesis.
Duration:
Between 21 and 35 days (mode: 28)
Lasting: 3-7days
Blood lost: 30-40ml

What is normal menstruation?

Menstrual periods usually last for 4 2
days, during which an average of 35-40
ml of blood is lost, an amount equivalent
to 16 mg of iron. The upper limit of normal
is 80 ml.

Menstrual disorders in the

reproductive period
Impaired long and the amount of menstrual blood
- Hipermenorea (menorrhagia)
- Hipomenore
Disorders of the menstrual cycle
- Polimenorea
- Oligomenorea
- Amenorrhoea
Disorders of bleeding outside the menstrual cycle
- Menometroragia
Other disorders associated with the menstrual
- Dysmenorrhea
- Premenstrual syndrome

What is abnormal menstrual bleeding?

Menorrhagia is prolonged (>7 days) or
excessive (>80 ml) uterine bleeding
occurring at regular intervals; it is
synonymous with hypermenorrhea
Metrorrhagia is uterine bleeding occurring
at irregular but frequent intervals, the
amount being variable
Menometrorrhagia is prolonged uterine
bleeding occurring at irregular intervals

 Polymenorrhea is uterine bleeding

occurring at regular intervals of <21 days
Oligomenorrhea is uterine bleeding more
than 35 days apart

Menorrhagia
The cause of menorrhagia is located on the
conditions in the uterus. Hemostasis in the
endometrium in the menstrual cycle is closely
related to platelet thrombin formation and fibrin
plugs vasoconstriction Hemostasis.
In von Willebrands disease and thrombocytopenia
occurred the component deficiency Menorrhagia
Anatomy Disorders : uterine myoma, polyps and
endometrial hyperplasia

hypomenore
Is menstrual bleeding with blood counts
fewer and / or shorter duration than
normal.
Etiology: organic disorders, such as
postoperative myomectomy on uterine
and endocrine disorders.

Polymenorrhea
is uterine bleeding occurring at regular
intervals of <21 days
It is difficult to distinguish polimenorea with
metroragia which is bleeding between the
two menstrual cycles.
Etiology: endocrine disorders that cause
ovulation disorders, and shortened luteal
phase ovarian congestion due to
inflammation.

Oligomenorrhea
Is uterine bleeding more than 35 days
apart
Common in polycystic ovary syndrome
caused by androgen hormones, causing
an increase in ovulation disorders.
Immaturity of the hypothalamic axis hipofisis- ovary - the endometrium.
Physical and emotional stress, chronic
diseases and nutritional disorders.

Cause of menstrual disorder

Pelvic pathology
Surface lesions in the genital tract
- Myoma uteri
- Endometrial polyps
- Endometrial hyperplasia
- Infection of the cervix, endometrium and uterus
- Trauma
inside lesions
- Myoma uteri
- Endometriosis
- Arterial venous malformations of the uterus
Diseases of the thyroid, liver, adrenal gland dysfunction
Hypothalamic pituitary disorders: adenoma, prolactinoma, stress
Systemic medical illness
- Disorders of hemostasis: Von wilebrand disease, other coagulation factor
disorders

Dysfunctional Uterine Bleeding

Prolonged # of days of bleeding or
excessive bleeding
Most common: anovulation
the lack of progesterone secretion increases
risk of endometrial hyperplasia
High estrogen
levels
Bleeding is
prolonged,
irregular and
sometimes
profuse
Adolescents
Obese

 At ovulation cycle dysfunction uterine bleeding caused by a

disruption of local control hemostasis and vasoconstriction
(Endothelin, prostaglandins, VEGF, and platelet lysosomal
enzyme) mechanism to limit the amount of bleeding
during the menstrual endometrial tissue release
In anovulatory cycles occur excessive estrogen stimulation
(unopposed estrogen) endometrial.
endometrial proliferation but had not followed by the
formation of a good tissue support due to low progesterone
levels endometrium becomes thick and brittle off
endometrial tissue is not the same and there is no collapse
the tissue irregular bleeding

DUB: Differential dx

Pregnancy
STDs
PID
Foreign bodies
Cervical neoplasia
Coagulation defect: vWF

DUB:
Treatment

 Nonhormon
- NSAIDs
- Antifibrinolisis (tranexamic acid)
surgical therapy
hysterectomy
endometrial ablation
myomectomy
Uterine artery occlusion

Amenorrhea
Primary: absence of menarche by age 16 in
the presence of normal pubertal development
(Tanner 4-5)
Or: lack of menses by age 14 in absence of
pubertal development

Secondary: absence of 3 consecutive

menstrual cycles or 6 months of amenorrhea

 Classification:
1.
2.
3.
4.

With pubertal delay

With normal pubertal development
Genital abnormalities
Hyperandrogenic anovulation

Amenorrhea
1. With pubertal delay

A. Hypergonadotropic
hypogonadism
OVARIAN FAILURE
Turner
XY gonadal dysgenesis
Autoinmmune oophoritis
Exposure to chemo or
RT(alkylating)
17 alpha hydroxylase
deficiency
Elevated FSH

Amenorrhea
1. With pubertal delay
B. Hypogonatropic hypogonadism
PITUITARY:

Adenoma

Prolactinoma

Craniopharyngioma

Hemochromatosis

Hypothyroidism

Breast stimulation

Sx

Phenothiazines, opiates
(-PRL inhibitor factor)

HYPOTHALAMIC:
Suppresion:
Stress
Malnourishment
Wt loss < 15% of ideal body
wt

Strenous exercise
Body fat < 22%
If prior to menarche, each yr
of training delays onset by 5
months

Prader-Willi
Kallman

Low or normal
FSH

Migration olfatory and GnRH

neurons)

Amenorrhea
2. with normal pubertal development
Pregnancy
Chronic diseases
Exc IBD, DM, hypothyroidism, anorexia
Use of hormonal contraceptive
Progestational effect
Uterine synechiae (Asherman sd)
Sheehan sd.

Amenorrhea
3. Genital tract abnormalities

Outflow tract-related:
Imperforate hymen
Transverse vaginal septum

Agenesis of the vagina, uterus:

Mullerian Agenesis: breasts, (+) pubic and axillary hair
Testicular feminization (x-linked defect androgen receptor): breast, (-)
pubic axillary hair

Amenorrhea
4. Hyperandrogenic anovulation
Hirsutism, acne, rarely
clitoromegaly
To be r/o:
1. PCOS (polycystic ovarian
syndrome)
Most common

2. Ovarian and adrenal tumor or

adrenal enzyme deficiency
3. Obesity

Primary amenorrhea
Presence of
breasts

TSH
PRL
MRI brain

testosterone
Enzymatic defect

Hormone

Surgery

Secondary
amenorrhea
>100ng/m
l

DHEAS: > 700ng/ml

Testosterone
>90ug/ml

Asherman

Abd-pelvic MRI
17OH
progesterone

Hirsutism: spirinolactone 50mg

po TID

Evaluation: Secondary amenorrhea

Progesterone challenge test:
Oral medroxyprogesterone acetate for 5-10 mg for 5-10
days), or IM 200mg x1.
POSITIVE TEST: withdrawal bleeding 2-7 days after
+uterus
+estrogen stimulation: ovaries ok

Estrogen-progesterone challenge test:

Oral conjugated estrogen (1.25 mg) or 2 mg estradiol qd for
days 1 through 21 with oral medroxyprogesterone acetate
(10 mg) on days 17 through 21.
POSITIVE TEST: withdrawal bleeding 2-7 days after
+uterus
Insufficient estrogen stimulation

Dysmenorrhea
(painful menses)
Primary:
Decrease of progesterone
levels al end of luteal phase:
lysosomal membranes are
unstable::::release enzymes
formation:
Prostaglandins
Keep increasing during luteal and
menstrual phases
Uterine hypercontractibility
Tissue ischemia
Nerve hypersensitivity
(just before or 1st days of menses)

Secondary:
Associated with pelvic
pathology:
Endometriosis
Miomas
PID
STD
Genital tract obstruction
(Later age, Menorrhagia,
Dyspareunia, Pain with defecation,
worsening with every cycle or midcycle, symptoms that persist after
menses have finished)

Dysmenorrhea: Treatment
Inhibiting prostaglandin synthesis:
Ibuprofen: 400-600mg po q4-6hrs
Naproxen 500mg load then 250mg po q6-8hrs
Started on 1st day of bleeding

Prevent ovulation and decrease

endometrial growth
Oral contraceptives
30-35mcg combined estrogen-progestin x46months

Laparoscopy

PMS
PMS is defined as a group of symptoms,
both physical and behavioral, that occur in
the second half of the menstrual cycle,
and that often interfere with work and
personal relationships

Symptoms of Premenstrual
Syndrome
1. Somatic symptoms

Bloated feeling
Feeling of weight increase
Breast pain or tenderness
Skin disorders
Hot flushes
Headache
Pelvic pain
Change in bowel habits

Symptoms of Premenstrual
Syndrome
2. Psychologic symptoms

Irritability
Aggression
Tension
Anxiety
Depression
Lethargy
Insomnia
Change in appetite
Crying
Change in libido
Thirst
Lost of concentration
Poor coordination, clumsiness,
accidents

Diagnosis

made by symptom diary and

elimination
of
other
diagnosis
such
as
psychiatric disorders like
depression, anxiety, and
psychosis.
PMS patients
suffer their symptoms only
during the luteal phase

SUMMARY

Thank You

Have a Good Day