Menstrual disorders

Learning Objectives
• Define the terms amenorrhoea, dysfunctional
uterine bleeding, dysmenorrhoea, menorrhagia, and
metrorrhagia
• Establish the causes of amenorrhoea, dysfunctional
uterine bleeding, dysmenorrhoea, Menorrhagia, and
metrorrhagia
• Describe the management of amenorrhoea,
dysfunctional uterine bleeding, dysmenorrhoea,
Menorrhagia, and metrorrhagia
 Introduction
 Menstrual disorders and abnormal uterine bleeding
(AUB) are among the most frequent gynecologic
complaints.

 Menstrual disorders frequently affect the quality of

life of adolescents and young adult women and can
be indicators of serious underlying problems.
 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.
The average adult menstrual cycle is 28 days,
with a range of 24 to 35 days , and lasts four to
six days.
 The median blood loss during each menstrual
period is 30 mL; the upper limit of normal is 80
mL.
H-P-O axis
Abnormal Uterine Bleeding
 Abnormal Uterine Bleeding…
Abnormal uterine bleeding refers to uterine bleeding
outside of the parameters noted below :
 Duration greater than eight days
 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 24 days or less
frequently than every 38 days
 Intermenstrual bleeding or postcoital spotting
 Absence of menses
 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
 Abnormal
Uterine
Bleeding

Anovulatory Ovulatory
Pathophysiology of Anovulatory Uterine Bleeding
 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.
 In anovulatory
cycles, the
follicular Ovary fails to
Endometrium
growth occurs secrete
Continuous, becomes Fragility and
with the progesterone,
unopposed E excessively irregular
stimulation although
stimulation of vascular endometrial
from FSH; estrogen
endometrium without stromal bleeding
however, due to production
support
lack of LH continues
surge, ovulation
fails to occur.
 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.
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
 Evaluation
 First, whom to evaluate ?
Patients with irregular cycles who should be
evaluated include
a) adolescents with 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.
 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.
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.
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
Ovulatory Uterine Bleeding
Ovulatory abnormal uterine bleeding, or
menorrhagia, presents as bleeding that occurs at
normal, regular intervals but that is excessive in
volume or duration.
 Etiologies
 Bleeding disorder
i. Factor deficiency
ii. Leukemia
iii. Platelet disorder
iv. von Willebrand disease
 Hypothyroidism
 Liver disease, advanced

 Structural lesions
i. Fibroids
ii. Polyps
Bleeding disorders Suspected if :
i. Menorrhagia since menarche
ii. Family history of bleeding disorders
iii. Personal 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.
 Types of Menstrual Disorders
• Common menstrual disorders include Amenorrhoea,
Dysfunctional Uterine Bleeding, Dysmenorrhoea,
Menorrhagia, and Metrorrhagia.
• Amenorrhoea: Absence of menstrual period.
• Dysfunctional Uterine Bleeding: Abnormal uterine
bleeding due to some disturbance of the menstrual
cycle, in the absence of organic condition such as
tumour and infections.
• Dysmenorrhoea: Pain during menstruation.
• Menorrhagia: Heavy and prolonged menstrual
bleeding.
• Metrorrhagia: menstrual bleeding occurring at
 Types of Menstrual Disorders
Amenorrhoea
• Can be classified as primary, secondary or
physiological.
• Primary Amenorrhoea: Failure of menarche to
occur when expected, in relation to the onset of
pubertal development.
o In Tanzania one study reported the general age of
menarche among school girls to be 14.3 +/- 1.1
years
o Usually if menarche does not start by the age 16
the girl should be evaluated for amenorrhea
 Amenorrhoea…..
• Primary Amenorrhoea can be caused by:
o Constitutionally delayed puberty
o Delayed puberty due to endocrine abnormalities
o Genetic abnormalities such as Turner syndrome and
gonadal dysgenesis (ovarian failure due to the premature
depletion of all oocytes and follicles)
o Uterine and vaginal anomalies, such as congenital absence
of the uterus, vaginal agenesis
o Anorexia nervosa, severe malnutrition
o Cryptomenorrhoea
o Obstruction, such as imperforate hymen or transverse
septum
o Hypothalamic hypogonadism
 Amenorrhoea…..
• Secondary Amenorrhoea: Absence of menstruation for
three or more months in a previously menstruating woman
of child bearing age (reproductive age).
• Secondary Amenorrhoea can be caused by:
o Pregnancy
o Hypothalamus/Pituitary Conditions
Intrinsic, including defective hypothalamus feedback
mechanism, pituitary tumour, hyperprolactinaemia,
pituitary adenoma
Extrinsic, including contraceptives, anorexia nervosa (low
estrogen production, resulting in ovarian
insufficiency/gonadal dysgensis can cause elevated FSH,
which in turn leads to premature menopause/amenorrhoea
 Amenorrhoea…..
• Secondary Amenorrhoea can be caused by:….
o Pseudopregnancy
o Anxiety/stress
o Ovarian condition such as premature menopause,
polycystic ovary disease and androgen-secreting
tumours
o Other endocrine disorders including hypothyrodism
and hyperadrenalism
o Local uterine causes/uterine disease
Uterine synechia caused by tuberculosis and
endometrial fibrosis
o Systemic cause, which may result from prolonged
 Amenorrhoea…..
• Physiological Amenorrhoea
o Occurs in physiological situation where
amenorrhoea is normal, including pregnancy,
lactation, menopause, and prior to the onset of
puberty.
 Dysfunctional Uterine Bleeding (DUB)
o Often results from anovulatory cycles. This causes
the change in the oestrogen/progesterone balance. It
is common in after menarche and perimenopausal
women.
 Dysmenorrhoea
• The causes can be described as primary or
secondary
• Primary Dysmenorrhoea
o There is no underlying cause; it is ascribed to be
due to prostaglandins release from the endometrium.
• Secondary Dysmenorrhoea
o It occurs in the presence of identifiable organic or
pathological cause.
o Common in older women and can be caused by
endometriosis, adenomyosis, pelvic inflammatory
disease, intrauterine adhesion (Asherman’s
syndrome), and cervical stenosis
 Menorrhagia
• The causes of menorrhagia include:
o Uterine tumours- Submucus myoma, endometrial
polyps
o Malignant tumours
o Adenomyosis
o Endometrial hyperplasia
o Endocrine disorders – hypothyroidism,
anovulatory bleeding
o Bleeding disorders
 Metrorrhagia
• The common conditions that lead to metrorrhagia
includes:
o Ovulatory bleeding – occurs in the midcycle as
spotting
o Endometrial polyps and submucosal fibroids
o Endometrial carcinoma
o Exogenous administration of estrogen/hormonal
contraceptive effects
o Endocrine disorders – hypothyroidism
o Cervical cancer
o Cervical/vaginal infection
 Management of Menstrual Disorders
Amenorrhoea
• Principles of management of amenorrhea
o Identify and treat the cause
o Refer for further tests
o Attempts to restore ovulatory function by hormonal
replacement therapy. Oestrogen and progesterone are
given to hypo-estrogenic amenorrheic women.
o Periodic progesterone should be taken by oestrogenic
amenorrheic women.
o Many cases require frequent re-evaluation by
gynaecologist
o To achieve pubertal development, conjugated
 Management of Menstrual Disorders….
Dysfunctional Uterine Bleeding (DUB)
• Treatment can be medical, surgical or combined
methods
o The choice of approach depends on:
The cause
Severity of bleeding
Patient's fertility status
Need for contraception
Treatment options available at the care site
 Management of Menstrual Disorders….
Dysfunctional Uterine Bleeding (DUB)…
• In severe bleeding with hemodynamic instability:
o Establish airway, breathing and circulation
o IV lines for fluids
o Oxygen
o Refer the patient to the hospital
o Otherwise all patient with DUB should be referred
• For patients who are stable, primary treatment
involves the use of combined oral contraceptive pills
or progesterone-only pills (e.g. primolut).
Management of Menstrual Disorders….
Dysmenorrhoea
• Treatment differs somewhat for primary and secondary
dysmenorrhoea.
o Primary dysmenorrhoea:
 Symptomatic approach
 Oral contraceptive to inhibit ovulation
 Analgesic
 Antiprostaglandins to suppress release of prostaglandins.
o Secondary dysmenorrhoea
 Treat the underlying cause
 Analgesic
 In case of endometriosis, hormonal therapy or surgery may be
indicated
Management of Menstrual Disorders….
Menorrhagia
• Treat the underlying cause

Metrorrhagia
• Treat the underlying cause with either surgical or
hormonal therapy
 Key Points
• Menstrual disorders are common in women of
child bearing age.
• A woman with uterine bleeding should not be
ignored, as the condition may become life
threatening.
• Before starting treatment, it is important to take a
proper history and conduct a physical examination
to obtain the correct diagnosis.