Abnormal menstruation - dr rabi

1. Dr Rabi NarayanSatapathyDepartment of Obst. & GynecologySCB Medical College, Cuttack, Odisha .

2. MENSTRUAL DISORDERS Dr Rabi NarayanSatapathy

3. Specific Objectives • By the end of this session the Students will be able to: • Define Normal menstruation • Classify Menstrual Disorders • Explain characteristics of the different menstrual disorders • Demonstrate ability to diagnose menstrual disorders • Apply Knowledge and skills acquired to manage menstrual disorders.

4. Definition of normal menstruation • It is the cyclical shading of a functional endometrium; and has the following characteristics: • Amount of flow: 25-80 ml average 30 mls • Cycle length: 21-35 days • Duration of flow: 2-7 days • Healthy menstrual blood does NOT coagulate • It occurs in a cyclic manner and regularly

5. Definition • Normal menstrual cycle involves hypothalamus-pituitary-ovary and uterus and is 28 days • Vaginal bleeding is abnormal (Abnormal Uterine Bleeding--AUB) when: • Volume is excessive or • Occurs at times other than expected, including during pregnancy or menopause • Known as dysfunctional uterine bleeding (DUB) when organic causes are excluded

6. AUB • Duration >7 days or • Flow >80ml/cycle or • Occurs more frequently than 21 days or • Occurs more than 90 days apart or • Intermenstrual or postcoital bleeding

7. Classification of menstrual disorders • Premenstrual syndrome (PMS) • Mastodynia • Abnormal bleeding due to gynecologic and non gynecologic disorders: • Amenorrhea, oligomenorhea, hypomenorrhea, menorrhagia, polymenorrhea, metrorrhagia, etc • Dysmenorrhoea • Dysfunctional uterine bleeding (DUB) • Post menopausal bleeding

8. Terminology • Menorrhagia: excessive flow • Metrorrhagia: Irregular & Acyclic Bleed • Menometrorrhagia: excessive volume • Oligomenorrhea: scanty flow • Dysmenorrhea: painful menstrual cycles

9. Characteristics of Menstrual disorders

10. Premenstrual syndrome: • occurs in at least 3 consecutive menstrual cycles • Symptoms must occur in the 2nd half of the menstrual cycle (luteal phase) • There must be a symptom free period of at least 7 days in the 1st half of the cycle • Symptoms must be severe enough to require medical advise or treatment e.g. oedema, weight gain, restlessness, irritability and increased tension.

11. Premenstrual syndrome cont’d: Symptoms include: • Mood symptoms ( irritability, mood swings, depression, anxiety) • Physical symptoms ( bloating, breast tenderness, insomnia, fatigue, hot flushes, appetite change, e.t.c) • Cognitive changes (confusion and poor concentration)

12. PMS -Diagnosis • Mainly based on patient’s history • Patient charts symptoms for at least 3 symptomatic cycles • Rule out medical conditions that mimic PMS e.g. thyroid disease and anemia.

13. PMS- Management( Conservative) • Diet: (limit caffeine, alcohol, tobacco and chocolate intake; eat small frequent meals • Decrease sodium intake • Stress management; • Aerobic exercises • Cognitive behavioral therapy

14. PMS management(Drug therapy) • Calcium carbonate (for bloating, pain and food cravings) • Magnesium ( for water retention) • Vitamin B6 and vitamin E • NSAIDs • Bromocryptine for mastalgia

15. Mastodynia • Also termed mastalgia • Defined as: intolerable breast pain during the second half of the menstrual cycle. • caused by edema and engorgement of the vascular and ductal systems • Occurs cyclically in the luteal phase

16. Mastodynia -diagnosis • History and examination • Can be confirmed by aspiration • Ultrasound • Serial mammography • Excisional biopsy sometimes is necessary • Rule out: Mastitis, neoplasm

17. Mastodynia- treatment • Breast support • Avoid- coffee, tea, chocolate, cola drinks • Avoid nicotine • May occasionally use a mild diuretic • Drug therapy: topical NSAIDS, Gosarelin (Zoladex), • Limited success with: tamoxifen, danazol, bromocryptine, oral contraceptives, vitamins

18. Menorrhagia (Hypermenorrhea) • Defined as excessive, heavy or prolonged menstrual flow • Possible causes include: submucous myomas, adenomyosis, IUDs, endometrial hyperplasia, malignant tumors e.t.c

19. Hypomenorrhea (cryptomenorrhea) • Defined as unusually light menstrual flow sometimes only spotting • Possible causes include: hymenal or cervical stenosis, uterine synechiae (Asherman’s syndrome), occasionally oral contraceptives

20. Metrorrhagia (intermenstrual bleeding) • Defined as bleeding occurring any time between the menstrual periods • Possible causes include: endometrial polyps, CA cervix, CA endometrium, exogenous estrogen administration

21. Polymenorrhea • Describes periods that occur too frequently • Usually associated with anovulation and rarely with a shortened luteal phase in the menstrual cycle

22. Menometrorhagia • This is bleeding that occurs at irregular intervals and varies in amount and duration of bleeding • Caused by any condition that can lead to intermenstrual bleeding

23. Oligomenorrhea • Describes menstrual periods that occur more than 35 days apart • Possible causes: anovulation which may be from endocrine causes (pregnancy, menopause, pituitary and hypothalamic disorders); or systemic causes (excessive weight loss); estrogen secreting tumors etc

24. AMENORRHEA • No menstrual period for more than 6 months • Possible causes: • Congenital uterine absence • Hormonal disturbances from the hypothalamus and pituitary gland • Failure of the ovary to receive or maintain egg cells • Genetic diseases e.g. causes of intersex i.e. 5-alpha-reductase deficiency

25. Diagnosis in abnormal uterine bleeding • History and physical examination • Cytological examination –include biopsy and histology • Pelvic ultrasound scan • Endometrial biopsy • Hysteroscopy • Dilatation and curettage • Hormonal profile • Blood tests- Haemogram, thyroid function tests e.t.c.

26. Management of abnormal uterine bleeding- principles • Treat cause appropriately May include • Hormonal preparations • Surgery • Endometrial ablation and endometrial resection, Prostaglandin synthetase inhibitors, • Levonogestrel releasing IUDs

27. Dysmenorrhea • Definition: Pain associated with menstruation • Risk factors: • Menstrual factors (early menarche, menorrhagia) • Parity (lower in multipara) • Diet (reduced intake of fish, eggs and fruits) • Exercise (reduces dysmenorrhoea) • Cigarette smoking (increases) • Psychological (emotionally dependent and overprotected girls, family history,)

28. Dysmenorrhea- classification • Primary or spasmodic dysmenorrhea: • Essential/ intrinsic / functional. Defined as painful menstruation in absence of pelvic pathology • Usually starts at puberty • Follows onset of ovulation and presents throughout period of bleeding. • Congestive or secondary dysmenorrhea: • Underlying pelvic disease e.g. uterine abnormalities, infections, endometriosis, foreign bodies, iatrogenic • Membranous dysmenorrhea: • associated with passage of endometrial cast through an undilated cervix.

29. Dysmenorhea- clinical features • Primary Dysmenorhea: • Age: Usually seen among younger women • Time of onset: 2-3 yrs after menarche • Duration of pain: starts just prior to menses, lasts about 2 days • Type of pain: cramping pain • Membranous Dysmenorhea: • Intense cramping pain associated with passage of an endometrial cast through an undilated cervix.

30. Dysmenorhea- clinical features (ctd) • Secondary Dysmenorhea: - Associated with specific diseases and disorders e.g. PID, Uterine fibroids, endometriosis etc • Usually among older women (3rd to 4th decade) • Time of onset: follows initial years of normal painless cycles • Duration of pain: Onset is few days prior to menses and continues throughout cycle even after cessation of menses • Type of pain: continuous dull aching or dragging pain

31. Dysmenorhea -management Dysmenorhea Assurance Laxatives Analgesics and Antispasmodics Fails Contraception not required or OC pills contraindicated Contraception required or NSAIDS contra indicated Prostaglandin synthetase inhibitors OC pills Fails Laparoscopy to look for causes of secondary Dysmenorhea No cause found but persistent and severe pain Cause found Treat as appropriate Surgery

32. Dysfunctional Uterine bleeding (DUB) • Defined as a symptom complex that includes any condition of abnormal uterine bleeding in the absence of pathologic cause • Commonly caused by anovulation as seen in polycystic ovarian disease and obesity • May occur in all age groups from prepubertal girls to menopausal women

33. DUB management • Medical management: • NSAIDS • Antifibrinolytic agents • Hormones • Surgical • Endometrial resection • Endometrial ablation • hysterectomy

34. Postmenopausal bleeding • Any vaginal bleeding in a postmenopausal women should be considered abnormal • Frequently associated with malignancies of the reproductive tract • Benign causes include: endometrial /cervical polyps, trauma, senile vaginitis, vulval dystrophies • Management depends on the cause.

35. Thank You