DEVIKHA PEREMEL

HYPOMENORRHEA
Hypomenorrhea defined as scanty
menstruation or a shortening of the duration
of menstruation.
Experiencing continuous reduced menstrual
flow and the bleeding lasts for less than 2 days
for repeated cycles, it is considered as
Hypomenorrhea.

Hereditary

Trauma

Hormonal
imbalance

Causes of
Hypomenorrhea

Psychological
reason

Contraception

Excessive
exercise

Causes of Hypomenorrhea
Hereditary: In few cases, hypomenorrhea may run in
families. If the disorder is due to constitutional
reasons, it normally does not affect fertility of the
woman.
Hormonal imbalance: The menstrual cycle largely
depends upon two hormones, estrogens and
progesterone. Any imbalance in the production of
these hormones gives rise to menstrual disorders.
Estrogen is responsible for creating the inner lining of
the uterus and low levels of this hormone causes very
thin uterus lining leading to hypomenorrhea.

 Continuous usage of contraception: Prolonged use of

pills or IUDs often results in endometrial atrophy leading
to scanty bleeding during periods. Hypothyroidism, one
of the causes for hormonal imbalance, occurs when the
pituitary gland does not function to its full potential and
fails to secrete the required TSH hormone.
Trauma: Any surgery or illness may cause damage to the
tissues of the endometrium and also reduces the cavity
of the uterine lining leading to scanty blood flow.
Excessive exercise: Working out or intense physical
exercise for long duration on a regular basis and losing
weight drastically also results in short and light periods.
Excess exercise may drop the fat content abnormally and
disturbs the hormone production causing light periods.
Psychological reasons: Hypomenorrhea can also be
associated with emotional disturbances and extreme
stress.

Other causes of scanty bleeding..

Malnutrition and anaemia caused by eating disorders like
anorexia can also reduce the blood flow leading to
hypomenorrhea.
Certain kidney diseases also give rise to hypomenorrhea.
Woman nearing menopause and undergoing perimenopause
experience scanty discharge for few months before total
cessation of menstrual cycle. This is a natural process
associated with menopause and does not need any medical
attention.
Polycystic ovarian syndrome (PCOS) and blocked fallopian
tubes also lead to scanty menses.
Ectopic pregnancy.

Investigations
Blood test for Hb level and hormones (e.g.
FSH, LH, estrogen, progesterone, thyroid
hormones, prolactin)
Ultrasonography for thickness of
endometrium, size of ovaries, ovulation,
growth of follicles as well as other
abnormalities
D&C and MRI for biopsy and examination of
the endometrium.

Treatment
Depends on the underlying cause.
If the blood tests reveal hormonal imbalance,
check the need for hormonal supplementation.
If fertility is an issue, then aggressive hormonal
treatment might be required.
The family history, age, previous menstrual
record and nutritional levels of the patient must
be considered.
Hypomenorrhea occurring due to genetic reasons
does not usually require any medical attention.

Menorrhagia (Hypermenorrhea)
Menorrhagia refers to prolonged (>7 days) or
excessive (>80ml) uterine bleeding or both
occurring at regular intervals.

The National Institute for Health and Care Excellence

(NICE) defines heavy menstrual loss as excessive
blood loss that interferes with a woman's physical,
social, emotional and/or quality of life.

Aetiology of Menorrhagia..
40-60% of those who complain of excessive bleeding have no
pathology and this is called dysfunctional uterine bleeding (DUB).
20% of cases are associated with anovulatory cycles and these are
most common at the extremes of reproductive life.
Local causes include:

Fibroids
Endometrial polyps.
Adenomyosis.
Endometritis.
Endometrial hyperplasia
Pelvic inflammatory disease (PID).
Carcinoma, especially endometrial carcinoma in women aged over 40;
this usually presents with postmenopausal bleeding, but 20-25% of
cases present with abnormalities of the menstrual cycle.

Systemic disease can include hypothyroidism, liver or kidney failure,

obesity and bleeding disorders - e.g., von Willebrands's disease.
An intrauterine contraceptive device (IUCD) or anticoagulant
treatment can increase menstrual flow.

History taking
Note the total duration of bleeding and how much (no.
of pads and presence of blood clots) of that time it is
heavy.
Note the length of the cycle.
Ask about other associated menstrual problems. E.g.
premenstrual syndrome, inter-menstrual
bleeding, postcoital bleeding, dyspareunia and pelvic
pain.
Ask about contraception and any symptoms to suggest
anaemia.
Ask about past medical problems, including clotting
disorders, thyroid status and gynaecological history.
Ask about easy bruising or bleeding gums.

Physical Examination
Clinical examination to assess for anaemia and to rule out
potential causes of menorrhagia.
- Note general appearance and BMI.
- Signs suggestive of endocrine abnormality (hirsutism,
acne) or bruising.
- Tongue for pallor and the nails for koilonychia.
- Examination of the abdomen: large pelvic masses may
present.
- Inspect the cervix and take swabs if clinically indicated.
- Perform a bimanual examination. Abnormalities may
include a bulky or grossly enlarged uterus, fixation of the
uterus or tenderness.

Investigations
Blood tests. May be evaluated for iron deficiency
anaemia and other conditions, such as thyroid
disorders or blood-clotting abnormalities.
Pap smear. Cervical smear collected and tested for
infection, inflammation or changes to detect
potentially pre-cancerous and cancerous processes in
endocervical canal.
Endometrial biopsy. Histological evaluation and to
exclude endometrial cancer or atypical hyperplasia.
Ultrasound scan. To determine structural
abnormalities of uterus, ovaries and pelvis.
Hysteroscopy.

Treatment
Medical (Drug
therapy)
1. Iron
supplements
2. NSAIDs
(ibuprofen)
3.Oral
contraceptives

Surgical treatment
1. D&C
2. Uterine artery
embolization
3. Myomectomy
(removal of uterine
fibroid)
4. Endometrial
ablation/resection
5. Hysterectomy

Metrorrhagia
Metrorrhagia is variable amounts of uterine
bleeding at irregular intervals, particularly
between the expected menstrual periods or
at frequent intervals.

Aetiology of Metrorrhagia..

Hormone imbalance (due to oral contraception).

Polyps or fibroids.
Infection or inflammation of the uterus, cervix, or vagina
Erosion of the cervix (loss of the surface skin of the cervix)
Use of an IUD (intrauterine device)
Endometriosis
Adhesions (scar tissue) inside the uterus
Dry vaginal walls from decreased estrogen after menopause
Chronic medical problems (E.g. thyroid problems, diabetes,
and blood-clotting problems)
Stress
Cancer of the cervix or other parts of the uterus and vagina

Investigation

Endometrial biopsy
Ultrasound scan
Sonohysterogram
Hysteroscopy
Hysterosalpingography

Treatment
Treat the cause:
- hormonal therapy for hormone imbalance
- remove IUD
- erosion of cervix treated by removing or destroying
some of the cervical tissue
Surgical treatment:
- D&C
- Hysteroscopy
- Hysterectomy
**If found to be cancer, treated with surgery, radiation or
chemotherapy or any combination of these treatments**