Management of

menstrual disorders
Dr O. BenGharbia
MRCGP, MD, MSc Sci

Case 1. Menorrhagia
A 43-year-old , got 2 children, LMP 21
days ago, presents with heavy
menstrual bleeding. In the last 6
months there has been a change with
menses coming every 25-32 days,
lasting 7-10 days and associated with
cramps not relieved by ibuprofen,
passing clots.
Prior to 6 months ago her cycles came
every 28-30 days, lasted for 6 days,
and were associated with cramps that

Conti, case 1
She denies dizziness, but complains

of feeling weak and fatigued.

Her weight has not changed in the
last year.
She denies any bleeding disorders
or reproductive cancers in the family.
She takes no daily medications and
has no other medical problems.
She is divorced , non smoker and
works as a teacher.

Conti, case 1
On examination;
BP=130/88; P= 100; Ht=158 cm; Wt=68 kg .

She appears pale.

No (hirsuitism, acne,ecchymosis/ purpura, signs
of thyroid, galactorrhea)
Pelvic exam shows normal vulva, vagina and
cervix: normal size, not tender, mobile uterus;
non-tender adnexae without palpable masses.
What are the parameters of a normal

menstrual cycle?

The parameters of a normal menstrual cycle

Interval 21-35 days (Mean: 28 days)

Duration: 2-7 days (Mean: 5 days)
Volume: <80ml (Mean 35 ml)
Composition: Non-clotting blood, endometrial
debris

The possible etiologies could

cause this patients bleeding?
PALM-COEIN is an acronym that was

published in 2011 by the International

Federation of Gynecology and Obstetrics .
Was created for the purpose of
establishing a universally accepted
nomenclature to describe uterine bleeding
abnormalities

The possible etiologies could

cause this patients bleeding
PALM-Structure Causes
Polyp
Adenomyosis
Leiomyoma
Malignancy and Hyperplasia
COEIN-Non-structural Causes
Coagulopathy
Ovulatory Dysfunction

Endometrial
Iatrogenic

Not Yet Classified

What are the appropriate lab tests that should be ordered in this patient?

CBC, TSH, Prolactin

Pregnancy Test
Endometrial Biopsy
Pelvic Ultrasound

Results of investigation
Labs show Hgb: 9 gr/100 dl., HCT: 27%, HCG:

negative, , TSH and Prolactin are within normal

limits.
Pelvic Ultrasound: heterogeneous myometrium,
endometrial lining 1.4cm with, normal ovaries.
Endometrial biopsy: normal secretary
endometrium.

What further tests would you order

based on the following results?

Further tests would you order?

Fluid-enhanced

sonohysterogram
Hysterosalpingogram
Diagnostic hysteroscopy

Endometrial evaluation of
menorrhagia
Endometrial
Biopsy

Sensitivity -91%

Transvaginal
Ultrasound (TVS)

Sensitivity -88%

False positive
rate -2%

Office procedure, well tolerated,

anesthesia and cervical dilation usually not
required
Good visualization of fibroids; may fail to
identify other intracavitary abnormalities
like polyps

Saline Infusion
Sonohysterosc-

Sensitvity -97%

Procedure of choice (detection and cost).

Sterile isotonic fluid is instilled into the
uterus under continuous visualization of

Opy (SIS)

endometrium with TVS

Hysteroscopy

Sensitivity -100%

Highest cost. Better in pre-menopausal

women. Does not reduce hysterectomy
rate even without intra cavitay path. Used
as gold standard for other procedures

How can you tell if this patient

is having ovulatory cycles?
History consistent with ovulatory cycles

(regular, presence of cycle)

Timed (luteal phase) endometrial biopsyis it secretory?
LH surge kits (ovulation prediction kits)
detect LH surge in urine which follows LH
surge in serum but occurs before ovulation
Basal body temperature chart with small
temperature increase (0.5 degrees) after
ovulation
Day 21 serum progesterone level.

Menorrhagia,

medical

management
NSAIDs, 30% 1 line, 5 days, decrease prostaglandins
Anti fibrinolyltic (transamine) 50% decrease in
st

blood flow)
OCPs, esp. if contraception desired, up to 60% dec. supp. HP axis
Oral continous progestins (day 5 to 26), most
prescribed, antiestrogen, downregulates endormetrium

Levonorgestrel IUD (Mirena),

approaches surgical techniques

High satisfaction rate that

GnRH agonists, Inhibit FSH and LH release hypogonadism, bone

Conjugated estrogens for acute bleeding
Danazol, Androgen and prog. competitor ,
amenorrhea in 4-6 weeks, androgenic side effects
Other treatments as indicated e.g. DDAVP for
coagulation defects
Combination can be used

Menorrhagia, surgical
management
Ablation

Myomectomy

polypectomy

Surgical

?D&C

Hysterectomy

Menorrhagia, surgical
management

Ablation

1st Generation
Resection
(TCRE)

2nd Generation

Cryoablation

Rollerball

Radiofrequency

Thermal
Baloon

Microwave

Menorrhagia, management summary

Tailor treatment to individual patient.
Consider patients age, coexisting

medical diseases, FH, desire for

fertility, cost of rx and adverse effects
Surgical management reserved for
organic causes (e.g fibroids) or when
medical management fails to
alleviate symptoms

Case 2; dysmenorrhea
A 14-year-old female comes to the clinic,

complaining of severe dysmenorrhea (painful

periods) for the past six months. She began
menstruating 10 months ago with her first
two periods occurring about 2 months apart
without pain or any other symptoms.
Since then, she menstruates every 28 days
and also notices nausea, diarrhea and
headaches during her periods. The pain has
gotten so bad for 3 days each month that
she often misses school.

Case 2 conti,

She is involved in sports and after

school programs, and you think it is

unlikely that she is pretending to
have dysmenorrhea to get out of
school. She denies use of drugs . She
says that she gets partial relief by
using 2-3 ibuprofen , two or three
times a day during her period.
The review of systems, past medical
history and social history are
noncontributory. The patients mother

Physical exam:
The patients general and systemic

examination were unremarkable .

Pelvic exam not done, a rectal exam
showing a normal size non-tender uterus,
which is mobile and anteflexed. There are
no nodules on the back of the uterus, and
there are no adnexal masses or tenderness.
Laboratory:
Urinalysis is negative for blood, nitrites and
leukocytes.

Discussion Questions
What is the differential diagnosis and

most likely diagnosis?

What additional evaluation is
needed?
How would you manage the possible
diagnoses ?

What is the differential diagnosis

and most likely diagnosis?
Primary dysmenorrhea is most likely; based on the

onset of pain and associated systemic symptoms,

as well as the partial response to NSAIDs
Secondary dysmenorrhea with underlying
endometriosis is less likely; based on the normal
physical examination, and the short interval since
menarche.
The patient may have an increased risk of
endometriosis due to her mothers history. Most
causes of secondary dysmenorrhea increase with
age such as structural abnormalities ( i.e.
leiomyomata, polyps).

What additional evaluation is needed?

A careful history is all that is needed in most

cases of primary dysmenorrhea.

No additional evaluation is needed for the
presumptive diagnosis of primary
dysmenorrhea.
However, if appropriate treatment fails to
relieve symptoms within 3 months, pelvic exam
and additional evaluation (such as ultrasound,
hysteroscopy or laparoscopy) is needed to rule
out a secondary cause such as endometriosis.

How would you manage the

diagnoses of primary
dysmenorrhea?
NSAIDs are first line treatment
Combination hormonal contraceptives (pills, or

patch) or progesterone-only contraceptive

(progesterone injection or implant) provide
effective contraception and improve symptoms of
dysmenorrhea.
NSAIDs are prostaglandin-synthetase inhibitors,
While hormonal contraceptives inhibit ovulation
and progesterone stimulation of prostaglandin
production.
Within three months of starting hormonal
contraceptives, 90% of women experience
improvement.

Case 3; Amenorrhea
A 26-year-old seen at clinic complaining of no
periods for 9 months. She got 2 children, ages are 5
and 3 years. She breastfed her youngest for 1 year,
menses returned right after she stopped, and were
monthly and normal until 9 months ago.
She is not using any contraception or any other
medication.
She feels very fatigued, has frequent headaches
and has had trouble losing weight.
She has no history of abnormal Paps or STIs.
She is married and works from home as a computer
consultant.

Examination
BP= 120/80, P= 64, Ht=164cm , Wt= 61 kg .
She appears tired but in no distress.
Breasts show scant bilateral milky white

discharge with manual stimulation. Breast

exam reveals no masses, dimpling or
retraction.
Examination otherwise normal, including
pelvic exam.
HCG is negative.

Discussion Questions:

1. Does this patient have primary amenorrhea,

secondary amenorrhea or oligomenorrhea?

2. What is the differential diagnosis for this
disorder?
3. What additional studies are needed?
4. Consider that this patient has a prolactin level
of above 130. The test when repeated with the
patient fasting is 100. What is your next step?
(normal range <22)
5. If the patient had a withdraw bleed to a
progestational challenge and a normal TSH and
prolactin, what would be the most likely
diagnosis, and what is first line treatment, and
long term concern if untreated.

Does this patient have primary or

secondary amenorrhea, or oligomenorrhea?

Primary amenorrhea definition: no

period at age 14 without secondary

sex characteristics, age 16 with
secondary sex characteristics.
Secondary amenorrhea definition: 6
months of amenorrhea after a history
of normal menses.
Oligomenorrhea: menstrual interval
>35 days but less than 6 months.

What is the differential

diagnosis for this disorder?
Pregnancy
Hypothalamic--Pituitary

Dysfunction (Pituitary adenoma, sever

Hypothyroidism, Medications, brain tumor,
chronic illness, excessive exercise &
stress,)
Ovarian Dysfunction (Premature ovarian
failure)
Genital Outflow Tract Abnormalities
Anovulation (Polycystic ovarian

What additional studies are

needed?
CBC, pregnancy test, TSH,
prolactin level, FSH,
Progestational challenge
(Progesterone challenge can
distinguish anovulation
hypogondism versus a pituitary
or hypothalamic etiology.

Results
Prolactin 12 ng/ml (normal range <22) &

TSH 1.2 uIU/ml (normal range: 0.4-4.0),

Progestational challenge is negative
consistent with hypogonadism
Next step in hypogonadism is FSH 80
uIU/ml. consistent with premature ovarian
insufficiency (POI)
Treat POI with HRT; replace estrogen in
order to protect against osteoporosis (and
progestin to protect the uterus

Consider that this patient has

a prolactin level of above 130.
when repeated with the
patient fasting is 100. What is
your next step
Pituitary MRI
Treat with dopamine agonist like

bromocriptine or surgical option.

If the patient had a withdraw bleed to a

progestational challenge and a normal TSH and
prolactin, what would be the most likely diagnosis,
first line treatment, and long term concern if
untreated?

Polycystic ovarian syndrome

If not wanting to conceive, COCP are best

first line treatment. If wanting to conceive,

ovulation induction with clomiphene citrate.
Long term the patient is at risk for
endometrial hyperplasia / uterine cancer if not
treated with progestins regularly.
Patient is also at increased risk of diabetes
and high cholesterol.

Case 4; postmenopausal bleeding

A 66 year-old nulliparous women who

underwent menopause at 55 years

complains of a 2- week history of vaginal
bleeding
Prior to menopause she had irregular
menses. She denies the use of oestrogen
replacement therapy
her medical history is significant for
diabetes mellitus & hypertension
controlled with an oral hypoglycaemic &
antihypertensive agent.

On examination;
84 kg weight, height 158cm
BP 150/90 mmHg and temp 37.1 c
The heart and lung exam are normal The

abdomen is obese and no masses are

palpated
the external genitalia appear normal
The uterus normal size with out adnexal
masses

Discussion Questions
What is the next step?
Perform an endometrial biopsy

What is your concern ?

Concern ; Endometrial Cancer

What is the risk factor for

endometrial cancer?

She undergoes endometrial sampling , and

is diagnosed with endometrial cancer

Which of the following is a risk

factor for endometrial cancer ?

a risk factor for endometrial

cancer ?
endogenous risk factors
increasing age
obesity and physical inactivity
low parity or infertility
diabetes mellitus
hypertension
early

menarche and late menopause

polycystic ovarian syndrome
family history
lynch syndrome (hereditary nonpolyposis colorectal cancer)
oestrogen secreting tumours (granulosa or thecal cell tumours of ovary)
history of breast cancer
immunodeficiency

exogenous risk factors

unopposed oestrogen only hormone replacement therapy
tamoxifen therapy
dietary factors
previous radiotherapy

Thank You