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Good Morning. Monday, August 8 th , 2011. Normal Menstrual Cycle. Normal Menstrual Cycle. 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

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  1. Good Morning Monday, August 8th, 2011

  2. Normal Menstrual Cycle

  3. Normal Menstrual Cycle • 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

  4. Abnormal Vaginal Bleeding • 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

  5. Abnormal Vaginal Bleeding • “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

  6. Differential Diagnosis • 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)

  7. Menorrhagia • 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

  8. von Willebrand Disease • 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

  9. Presentation 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!)

  10. History • 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

  11. Medications • Depo • OCPs • IUDs • Psychotropic medications • Risperidone • Illicit drugs • Herbs • Dietary supplements

  12. Exam • 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

  13. *Labs • CBC • UPT (exclude pregnancy in everyone!!) • PT • 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)

  14. *Management • 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)

  15. Iron Therapy 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

  16. Noon Conference Immunizations, Dr. Begue

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