MENSTRUAL DISORDERS

Muhammad Hasanudin Bin

Misebah
Megat Mohd Azman Bin Adzmi
Paula Reubavathi Selvarajoo

Menstrual Disorders
Abnormal/irregular menstrual patterns are
common during the first 2 years after
menarche
Variability in cycle length is greater during
adolescence than adulthood
thus greater irregularity is acceptable if
significant anemia or hemorrhage is not
present

Common menstrual disorders are

amenorrhea, abnormal/excessive uterine

Menstrual Disorders
Length of the normal menstrual cycle is highly
variable.
Normal menstrual cycles are characterized by a cycle length
of 28 days ( 7 days),
a duration of flow of 4 days ( 2 days), and a blood loss of
40 mL ( 20 mL)
The mean volume of loss is 43 mL, with a normal range of
20-80 mL

Cycles are abnormal

If longer than 8 to 10 days in duration or
if more than 80 mL of blood loss occurs,
particularly after first 2 years from onset of menarche.

Amenorrhea
Amenorrhoea is complete absence or
cessation of menstrual bleeding for
greater than 6 months
Amenorrhea-except that occurring before
puberty, during pregnancy or early
lactation, and after menopause-is
pathologic.
Amenorrhea may be caused by:
anatomic abnormalities
hypothalamic, pituitary, or other endocrine
dysfunction;
ovarian failure; or

Amenorrhea
Primary amenorrhoea
Primary amenorrhoea is defined as no
spontaneous onset of menstruation by the age
of 16 years.
Secondary amenorrhoea
Secondary amenorrhoea is defined as the
absence of menstruation for more than 6
months of longer if the patient has previously
experienced regular menses and for 12 months
or more when a patient has oligomenorrhoea.

Classification of causes of
amenorrhoea
Physiological

Pathological

Reproductive outflow
tract abnormalities.
Ovarian disorders.
Pituitary disorders.
Hypothalamic
disorders.
Miscellaneous
endocrine disorders.

Prepuberty
Pregnancy
Lactation
Postmenopause

Reproductive outflow tract

obstruction
Mullerian agenesis:

Congenital absence of vagina or uterus or both

Called Mayer-Rokitansky-Kuster-Huaser syndrome
1:4000 female
Ovarian function is usually normal
Associated renal abnormalities are not uncommon

Transverse vaginal septum

Failure of the lower third of vagina to canalize

Imperforate vagina
Primary amenorrhoea with cyclical pain and
difficulty in micturition

Reproductive outflow tract

obstruction
Androgen insensitivity (testicular feminization)
XY karyotype
Gonad is testes.
Normal testosterone level
Congenital defect of androgen receptor
Develop external genitalia
No uterus and have an absent vagina or blind vagina
Need to excise testes bec. of 20% risk of malignancy

Cervical stenosis
Ashermans syndrome

Ovarian causes
Anovulation
Most common is PCOS
Other endocrine disorders; eg,
hyperprolactinaemia

Gonadal dysgenesis
Rudimentary gonad, Primary amenorrhoea,
sexual infantilism, elevated gonadotrophin
level
Causes
Turners syndrome (45 XO and mosaic form)
Pure gonadal dysgenesis (46 XX)
Swyer syndrome: rare, due to loss of germs cell early
in fetal life

Ovarian causes
Premature ovarian failure
Onset of menopausal symptoms and elevated
gonadotrophin levels before 40 years
Causes
Unknown
May result from irradiation, chemotherapy,
autoimmune disease, Infection (mump)

Resistant ovary syndrome

Elevated gonadotrophin levels despite the
presence of viable follicles within the ovary
In most cases, it is temporary condition

Pituitary
Hyperprolactinaemia (primary cause of
amenorrhoea in 20% of cases)
Pituitary adenoma
Micro-adenoma
Macro-adenoma (compression of optic nerveVisual
symptom)

Pituitary insufficiency
Failure to secrete gonadotrophin
Most common cause is necrosis of pituitary as a
result of obstetric haemorrhage (Sheehan's
syndromes)

Hypothalmic disorders
Functional hypogonadotrophic
hypogonadism
Exercise
Stress
Weight loss
Drug-induced

Injected depo Provera

Danazole
GnRH agonist
After COC pill

Hypothalmic disorders
Non functional hypogonadotrophic
hypogonadism
Space occupying lesion;
Craniopharyngioma, Tuberculosis, sarcoidosis

Kallmanns syndrome
Congenital disorder
Primary amenorrhoea, infantile sexual
development, anosmia

Miscellaneous endocrine
disorders.
Hypothyroidism
TSH elevated
Prolactin elevated

Cushings syndrome
Increased adrenal activity hyperandrogenic
state

Amenorrhea Without
Secondary Sexual
Characteristics

Galactorrhea and amenorrhea

Hypothyroidism, breast stimulation, stress

associated with trauma or surgery, and certain
drugs (phenothiazines, opiates).

Hypergonadotropic hypogonadism
Caused by primary ovarian failure associated
with elevated gonadotropin levels. An elevated
FSH will establish the diagnosis.

Amenorrhea Without Secondary

Sexual Characteristics
Pituitary gland
congenital hypopituitarism, tumor (pituitary
adenoma), or infiltration (hemochromatosis).
Prolactinoma is the most common pituitary
tumor. (present with galactorrhea, headache,
visual fields cuts, and amenorrhea. Elevated
prolactin levels are characteristic)
Craniopharyngioma is another tumor of the
sella turcica that affects hypothalamic-pituitary
function, presenting with pubertal delay and
amenorrhea.

Amenorrhea Without
Secondary Sexual
Characteristics

Hypogonadotropic hypogonadism

Caused by hypothalamic dysfunction or

pituitary failure.
Low or normal levels of LH and FSH
Decreased estradiol levels may be present.

Ovarian failure
Autoimmune disorders or exposure to radiation
or chemotherapy may also cause amenorrhea
with pubertal delay.

Hypothalamic abnormalities associated

with pubertal delay
Kallmann syndrome and others. (anosmia)

Amenorrhea Without Secondary

Sexual Characteristics
Sheehan syndrome (pituitary infarction)
suggested by a history of intrapartum bleeding
and hypotension in parous women.

In a pubertal female
pregnancy should be ruled out if there is sexual
exposure and amenorrhea.

Uterine synechiae (Asherman syndrome)

suspected in amenorrheic patient with a
history of abortion, dilation and curettage, or
endometritis.

Amenorrhea Without
Secondary Sexual
Characteristics

Turner syndrome

May cause ovarian failure and a lack of

pubertal development.
Commonest chromosomal abnormality causing
gonadal failure and primary A.
Females with this syndrome have streak
gonads, absence of one of the X chromosomes,
and inadequate levels of estradiol.
No puberty or uterine development.
Characterized by short stature, webbed neck,
widely spaced nipples, shield chest, high
arched palate, congenital heart disease, renal
anomalies, and autoimmune disorders

Amenorrhea Without
Secondary Sexual
Characteristics

Anatomical abnormalities

imperforate hymen, transverse vaginal

septum, agenesis of the vagina may also
present with amenorrhea.

Ovarian failure, prolactinomas, thyroid

disease, and stress, athletes (excessive
exercise), eating disorder (anorexia
nervosa)
May cause amenorrhea after normal pubertal
development.

Polycystic ovarian disease may also

present with amenorrhea.

Treatment
Management depends on the cause.
restoring ovulatory cycles if possible in the
adolescent with constitutional delay and
anovulation,
replacing estrogen when necessary,
reassurance to alleviate the tremendous
anxiety of the patients, and re-evaluation.

Treatment
Surgery - Ovarian cysts , uterine
problems, specific therapies.
Commonest pregnancy should always be
excluded.
Easing up on excessive exercise and
eating a proper diet in teen athletes.
Hyperprolactinaemia often responds to
bromocriptine.
Prolactinomas will commonly shrink with
medical therapy, but large tumours may need
surgery.

Treatment
Hypothyroidism is treated with
levothyroxine.
Other tumours of the pituitary,
hypothalamus, ovary, and adrenal glands
usually require surgery.
Genital tract malformations e.g.
haematocolpos.
Hypothalamic amenorrhoea
Pulsatile GnRH.

Treatment
Amenorrhoea secondary to pituitary
disease (excluding prolactinomas)
Gonadotrophins.
Glucocorticoids should be used only for
documented adrenal hyperfunction or enzyme
defects in the steroidogenic pathway.

All women with low oestrogen levels

should be considered for oestrogen
replacement especially for prevention of
osteoporosis.

Treatment
Polycystic ovary syndrome (PCOS)
may respond to weight loss, and recently there
has been interest in the
use of insulin-sensitizing agents, e.g.
metformin.
Clomiphene citrate is the first choice to induce
ovulation.
Other methods include exogenous
gonadotropin, human purified FSH, ovarian
wedge resection, and ovarian drilling.
For those who are not hirsute, and do not
desire pregnancy, an intermittent progestin
(medroxyprogesterone acetate 5 to 10 mg/day

Oligomenorrhoea
Oligomenorrhoea is the reduction
of frequency of menstruation where
menstrual intervals may vary
between 6 weeks and 6 months.

Oligomenorrhea
Infrequent or light menstrual cycles
Very common in early postmencharchal period and not
usually worrisome.
At menarche often do not have regular cycles for a few
years.
Some periods may occur every three weeks and in
others, every five weeks. Flow also varies and can be
heavy or light.
Should be concerned
When periods come less than 21 days or more than 2 to 3
months apart,
If they last more than eight to ten days. Such events may
indicate ovulation problems.

Dysmenorrhea
Etiology:
Primary dysmenorrhea: caused by increased
prostaglandin production by the
endometrium in an ovulatory cycle which
cause contraction of the uterus. The highest
level is in the first 2 days of menses.
Secondary dysmenorrhea: is painful
menstruation due to pelvic or uterine
pathology.

Causes of Secondary
Dysmenorrhea
Endometriosis
Ectopic implantation of the endometrial tissue in
other parts of the pelvic, its the most common cause
of dysmenorrhea

Adenomiosis
Ingrowth of the endometrium into the uterine
musculature.

Fibroids
Pelvic infection
Intrauterine device
Cervical stenosis
Congenital uterine or vaginal abnormalities

Clinical manifestation
Sharp, intermittent spasm, usually in
subrapupic area.
Pain may radiate to the back of the leg or
the lower back
Systemic symptoms:

Nausea
Vomiting
Diarrhea
Fatigue
Fever
Headache or dizziness

Assessment
Focused history and physical examination:
Primary dysmenorrhea: cramping pain
with menstruation and the physical
examination is completely normal
Secondary dysmenorrhea: the history
discloses cramping pain starting after 25
years old with pelvic abnormality.

history of infertility
heavy menstrual flow
irregular cycles
little or no response to NSAIDs

Assessment
Detailed sexual history to asses for
inflammation or scaring
Bimanual pelvic examination in
nonmenstrual phase of the cycle
Laboratory tests for:

CBC to R/O anemia

Urine analysis to R/O bladder infection
Pregnancy test
Cervical culture to exclude STI
ESR to detect an inflammatory process
Pelvic and vaginal U/S
Diagnostic laprascopy or lapratomy

Treatement
Pain relief : NSAIDs, cyclooxygenase- 2
inhibitor
Hormonal contraceptives
Life style changes:

Daily exercise
Limit salty foods
Weight loss
Smoking cessation
Relaxation techniques

Abnormal Uterine
Bleeding
Vast majority of abnormal bleeding in
adolescents is caused by immaturity of the
hypothalamic-pituitary-ovarian (HPO) axis
resulting in anovulatory menstrual cycles
DUB is defined as abnormal and
excessive endometrial bleeding without
structural pathology
some, the bleeding is secondary to problems
of pregnancy, uterine pathology, exogenous
hormone use and systemic bleeding disorders.

Abnormal Uterine
Bleeding
Particularly common during adolescence and
perimenopausal periods.
Diagnosis by exclusion.
Diagnosis only made in the absence of
hirsutism or galactorrhea as revealing
symptoms of functional ovarian
hyperandrogenism, polycystic ovary syndrome,
late form of congenital adrenal hyperplasia or
hyperprolactinemia; ovarian failure.
Coagulation disorders must always be
excluded.

Types of uterine bleeding

disorders

Amenorrhea : (absence of menstruation)

Hypomenorrhea : (scanty menstruation)
Oligomenorrhea : (infrequent menstruation,
periods more than 35 days
apart),
Menorrhagia : (excessive menstruation),
Metrorrhagia : (bleeding between periods).
Menometrorrhagia : (is heavy bleeding during
and between menstrual
periods).

Etiology Abnormal Uterine

Bleeding

Adenomiosis
Pregnancy
Hormonal
imbalance
Fibroid tumors
Endometrial
polyps or cancer
Endometriosis

IUCD
Polysystic ovary
syndrome
Morbid obesity
Steroid therapy
Hypothyroidism
Clotting disorders

Clinical manifestation

Vaginal bleeding between periods

Irregular menstrual cycle
Infertility
Mood swings
Hot flashes
Vaginal tenderness
Menstrual flow either scanty or profuse
Obesity
Acne
Diabetes: insulin resistance is common

Characteristics of ovulatory
and anovulatory menstrual
cycles

Assessment
History taking
Assist in pelvic examination to identify any
structural Abnormalities
Laboratory tests:

CBC to reveal anemia

PT to detect blood disorders
BHCG to rule out abortion or ectopic pregnancy
TSH to screens for hypothyroidism

Transvaginal ultrasound to measure

endometrium
Pelvic ultrasound
Endometrial biopsy to check intrauterine
pathology

Treatment
It depend on the cause and age of the
client
The aims in treatment of DUB:
to control bleeding,
prevent recurrences,
preserve fertility

Treatment
Medical care with pharmacotherapy:
Estrogen: cause vasospasm of the uterine
arteries to decrease bleeding
Cyclic progesterone or long acting
progesterone
Oral contraceptives: regulate the cycle and
suppress the endometrium
NSAIDs inhibit prostaglandin
Iron replacement

Treatment
If the client doesnt respond to medical
therapy:
Dilated and Curretage
Endometrial ablation: is an alternative to
hysterectomy
Thermal balloon to ablate the endometrium

In the adolescents, reassurance simply

observe anovulatory cycles while awaiting
maturation of the HPO axis.

Treatment
Regular cycling with a progestogen, or
combined oral contraceptives (OCP), to
regulate the menses.
Progestogen therapy administered
cyclically
In the second half (luteal phase treatment from
the 15th to the 25th day)
Throughout the menstrual cycle (whole cycle
treatment-from the 5th to the 25th day).

Treatment
Acute heavy bleeding with hypovolemia
Volume resuscitation
Be hospitalized
High-dose intravenous estrogen
Usually, the bleeding is controlled within 24
hours and switched to oral combined pills for
21-25 days.
An alternative is to start treatment with
combination estrogen/progestin preparations
(OCP) 3-4 tablets per day with eventual tapering
of the dose over 3-4 weeks.