MENSTRUAL

DISORDERS

Blanca De Guia, M.D., MSc

Professor
Department of Obstetrics and Gynecology
UP – Philippine General Hospital
 Although the absence of
menses causes no harm to
the body in a woman who is
not pregnant or postpartum, it
is abnormal and thus is a
source of concern. For this
reason, women usually seek
medical assistance when this
condition occurs.
DEFINITION OF TERMS
Primary amenorrhea
• absence of menses in a
woman who has never
menstruated by age 16 ½
years
Secondary amenorrhea
• absence of menses for an
arbitrary period, usually 6 to
12 months
ONSET OF MENARCHE
• The mean interval between
breast budding and menarche
is 2-3 years.

• The absence of breast

budding is indicative of a lack
of estradiol synthesis.
ONSET OF MENARCHE

• The ratio of fat to both total

body weight and lean body
weight is the most relevant
factor that determines onset
of puberty and menstruation.
ONSET OF MENARCHE

• Moderately obese individuals

have earlier menarche than
non-obese women.

• Malnutrition is known to delay

onset of puberty.
 Classification of Disorders with
Primary Amenorrhea and Normal
Female External Genitalia

I. Absent breast development;

uterus present
A. Gonadal failure
• 45, X (Turner syndrome)
• 46, X abnormal X (eg. Short- or
long- arm deletion)
• Mosaicism (eg. X/XX, X/XX/XXX)
• 46, XX or 46, XY pure gonadal
dysgenesis
• 17 α-hydroxylase deficiency with
46, XX
 Classification of Disorders with
Primary Amenorrhea and Normal
Female External Genitalia

B. Hypothalamic failure
secondary to inadequate
GnRH release
• Insufficient GnRH secretion due to
neurotransmitter defect
• Inadequate GnRH synthesis
(Kallman syndrome)
• Congenital anatomic defect in
central nervous system
• CNS neoplasm
(craniopharyngioma)
 Classification of Disorders with
Primary Amenorrhea and Normal
Female External Genitalia

C. Pituitary failure
• Isolated gonadotrophin insufficiency
(thalessemia major, retinitis
pigmentosa)
• Pituitary neoplasia (chromphobe
adenoma)
• Mumps, encephalitis
• Newborn kernicterus
• Preperpetual hypothyroidism
 Classification of Disorders with
Primary Amenorrhea and Normal
Female External Genitalia

II. Breast development;

uterus absent

A. Androgen resistance
(testicular feminization)
B. Congenital absence of
uterus (utero-vaginal
agenesis)
 Classification of Disorders with
Primary Amenorrhea and Normal
Female External Genitalia

III. Absent breast

development, absent uterus
– 17,20- desmolase deficiency
– Agonadism
– 17 alpha hydroxylase deficiency
with 46 XY karyotype
 Classification of Disorders with
Primary Amenorrhea and Normal
Female External Genitalia

IV. Breast development

present; uterus present
A. Hypothalamic etiology
B. Pituitary etiology
C. Ovarian etiology
D. Uterine etiology
 Secondary
Amenorrhea

A. Uterine Cause
– Asherman syndrome –
intrauterine adhesions or
synechiae
– Most common cause –
endometrial curettage
 Secondary
Amenorrhea
B. Ovarian Cause
• Premature ovarian failure
– the ovaries cease to
produce sufficient estrogen
to promote endometrial
growth before age of
physiologic menopause
(age of 40)
 Secondary
Amenorrhea
• Two ovarian pathologic
findings
1. generalized sclerosis like
menopause
2. primordial follicles with no
progression (gonadotropin
resistant ovary)
• Etiology: may be autoimmune
disease as hypoparathyroidism,
Hashimoto’s thyroiditis, or Addison’s
disease
 Secondary
Amenorrhea
C. Pituitary Cause
1. Prolactin-secreting and
non-prolactn secreting
adenomas
2. Non-neoplastic lesions
as Sheehan syndrome
and Simmourad
disease
 Secondary
Amenorrhea
D. CNS- Hypothalamic
cause
1. Drugs as phenothiazine
derivatives
2. Stress and exercise
3. Weight loss
4. Polycystic ovary syndrome
5. Functional hypothalamic
amenorrhea
Evaluation of Secondary
Amenorrhea
History and Physical Examination
– Pregnancy
– Instrumentation for
intrauterine adhesions
– Use of OCP
– Diet, weight loss, stress and
exercise
– Hot flushes, vaginal dryness,
etc
Evaluation of Secondary
Amenorrhea

Laboratory Examination
– complete blood count
– urinalysis
– serum chemistries
– serum TSH
– prolactin levels
– E2
– FSH
ABNORMAL UTERINE
BLEEDING
 ABNORMAL UTERINE
BLEEDING
• Abnormal uterine bleeding is
a clinical problem of great
magnitude – affecting women
of all ages. Sequelae include
anemia, lassitude, and
associated social, economic,
and psychological
consequences that result in a
diminished quality of life.
 Definition of Terms
What is normal menstruation?

• Menstrual periods usually last

for 4 ± 2 days, during which
an average of 35-40 ml of
blood is lost, an amount
equivalent to 16 mg of iron.
The upper limit of normal is 80
ml.
 Definition of Terms
What is abnormal menstrual
bleeding?

• Menorrhagia is prolonged (>7

days) or excessive (>80 ml)
uterine bleeding occurring at
regular intervals; it is
synonymous with
hypermenorrhea
 Definition of Terms
• Metrorrhagia is uterine
bleeding occurring at irregular
but frequent intervals, the
amount being variable

• Menometrorrhagia is
prolonged uterine bleeding
occurring at irregular intervals
 Definition of Terms
• Intermenstrual bleeding
is bleeding at variable
amounts occurring
between regular menstrual
periods
 Definition of Terms
• Polymenorrhea is uterine
bleeding occurring at
regular intervals of <21
days

• Oligomenorrhea is
uterine bleeding more than
35 days apart
What causes endometrial
bleeding during menses?

1. The systemic trigger of

menstrual bleeding is
progesterone withdrawal
from an estrogenically
primed endometrium
What causes endometrial
bleeding during menses?

2. The local mechanism

involved is spiral artery
vasoconstriction with
resultant ischemia necrosis
of the endometrium.
– The responsible agents is the
prostaglandin F2 and another
vasoconstricting agent
endothelin-1
What causes endometrial
bleeding during menses?

Another local mechanism is

the release of matrix
metalloproteinase (MMP)
– MMP-1 (interstitial
collagenase)
– MMP-2 (gelatinase)
– MMP-3 (stromolysis)
What causes endometrial
hemostasis?

1. Formation of primary
platelet plug (primary
hemostasis)

2. Stabilization of plug by
activation of coagulation
cascade and thrombin-
induced conversion of
fibrinogen to fibrin
(secondary hemostasis)
 What is responsible for
endometrial repair and
regeneration?
• Estrogen stimulate
epithelization and then
proliferation of stromal,
glandular, and epithelial cells

• Both estrogen and thrombin

stimulate angiogenesis
(development of capillaries
from existing vessels)
 What are the causes of
abnormal uterine bleeding?

• Organic cause which can

be systemic or
reproductive
• Dysfunctional or
endocrinologic cause
 What are the causes of
abnormal uterine bleeding?
I. Organic Causes
A. Systemic
1. Coagulopathies
2. Arteriovenous malformation
3. Iatrogenic causes
– Anticoagulants
– Tamoxifen induced
– Psychotropic drugs
– Gonadal steroid
– Operative procedure (curettage,
colposcopy, etc)
4. Disease
– Chronic liver disease
 What are the causes of
abnormal uterine bleeding?
B. Reproductive
1. Pregnancy
2. Leiomyomas
3. Polyps
4. Inflammation
5. Intrauterine device
6. Endometrial
hyperplasia/neoplasia
7. Adenomyosis
 What are the causes of
abnormal uterine bleeding?

II. Dysfunctional Causes

– Dysfunctional bleeding
occurs when it is unrelated to
demonstrable organic cause
 What are the causes of
abnormal uterine bleeding?

Anovulatory DUB
• There is an absence of
cyclic production of ovarian
progesterone and bleeding
is thus erratic in nature and
irregular in both timing and
volume.
 What are the causes of
abnormal uterine bleeding?
• An important clinical
complication of
anovulatory DUB is the
creation of an endometrial
milieu of unopposed
estrogen and thus it
facilitates development of
endometrial hyperplasia
and adenocarcinoma.
 What are the causes of
abnormal uterine bleeding?
• Causes of Anovulation
• Immaturity of HPO axis
• Clinical or subclinical
hypothyroidism
• Hyperandrogenic states as
ovarian or adrenal tumor,
congenital adrenal hyperplasia,
PCOS
• Hyperprolactinemia
• Use of gonadal steroids
• Eating disorders
• Strenuous exercise
 How do we evaluate
abnormal menstrual
bleeding?
I. History
– Detailed history of bleeding and
menstrual bleeding
– Pregnancy
– Ovulatory or anovulatory states
– Predictable, cyclic menses with
molimina→ ovulatory
– Irregular flow in timing and amount
→ anovulatory
– Woman’s lifestyle
– Family history
– Detailed medical history of patient
 How do we evaluate
abnormal menstrual
bleeding?
II. Physical Examination
• Aside from general
examination, one must
include:
• For ovulatory woman, look
for evidence of
coagulopathy or systemic
disease
 How do we evaluate
abnormal menstrual
bleeding?
For anovulatory women:
• body habitus
• source of stress or
psychiatric disorders
• identify discrete entities as
hirsuitism, thyromegaly,
galactorrhea
 How do we evaluate
abnormal menstrual
bleeding?
Pelvic examination
• Perineum/perianal area –
lacerations, tumor
• Vagina – laceration
• Cervix – dusky hue of
pregnancy, polyp, ectropion,
malignancy, infection
• Corpus – pregnancy, myoma or
adenomyosis
• Adnexa – pelvic
mass/tenderness
• Cul de sac/Fornices –
hemoperitoneum, pelvic mass
 How do we evaluate
abnormal menstrual
bleeding?
III. Laboratory Examination
– Hemoglobin/hematocrit
– If at risk for coagulopathy:
• Platelet count
• Peripheral smear
• APTT
– If ovulation uncertain:
• TSH
• Prolactin
• Testosterone
– Endometrial biopsy or curettage or
hysterectomy and ultrasound for
endometrial evaluation
 Management

1. Treat the cause

3. Medical Management
a. Iron – 60-180 mg a day
b. Antifibrinolytics (Tranexamic acid) –
mainstay for ovulatory bleeding
c. Cyclooxygenase inhibitors
(NSAIDS)
 Management
2. Medical Management
d. Progestins
• Likely to be effective in
anovulatory bleeding
• Continuous administration may
be better than cyclic
e. Estrogens
f. Estrogens plus progesterone (pills)
g. Androgens (danazol) – weight gain,
acne, oily skin, may be side effects
h. GnRH agonists – few studies
 Management
3. Surgery
– Polypectomy
– Myomectomy
– Endometrial ablation or
resection
– Hysterectomy
DYSMENORRHEA
DEFINITION OF TERMS
Dysmenorrhea
• a severe, painful cramping
sensation in the lower
abdomen often accompanied
by other symptoms as
sweating, tachycardia,
headaches, nausea, vomiting,
diarrhea, and tremulousness
all occurring just before or
during the menses.
DEFINITION OF TERMS
• Primary – reserved for
women who had no obvious
pathologic condition, almost
always occurs in women
younger than 20

• Secondary – associated with

conditions or pathology that
causes pelvic pain in
conjunction with menses
 Factors Affecting
Dysmenorrhea
• A significant positive correlation is
seen between the severity of
dysmenorrhea and the duration of
menstrual flow, amount of
menstrual flow, and early
menarche

• Dysmenorrhea is significantly
increased among mothers and
sisters of women with
dysmenorrhea
 Treatment of Primary
Dysmenorrhea

• Nonsteroidal anti-inflammatory
drugs (NSAIDs) are prostaglandin
synthetase inhibitors and are
considered the treatment of
primary dysmenorrhea.
• Other therapy include oral
contraceptives, analgesics and
transcutaneous electrical nerve
stimulation.
 Causes of Secondary
Dysmenorrhea
Cervical stenosis
Endometriosis and
adenomyosis
Pelvic infection and adhesions
Pelvic congestion
Conditional behavior
Stress and tension
Treatment of Secondary
Dysmenorrhea

These consists mainly of

• medical management of pain
• Counseling
• relief from stress and tension
Treatment of Secondary
Dysmenorrhea
Surgical treatment
• cervical dilatation for stenosis
• adhesiolysis for pelvic
adhesions
• cystectomy and excision of
implants for endometriosis
• Hysterectomy is reserved fro
those without pain relief.
 Endometriosis
• It is the presence and
growth of the glands and
stroma of the lining of the
uterus in an aberrant or
heterotropic location.
 Endometriosis
Etiology
• Retrograde menstruation
• Metaplasia
• Lymphatic and vascular
metastasis
• Immunologic change
• Genetic predisposition
 Endometriosis
• Symptoms: dysmenorrhea,
dyspareunia, abnormal
bleeding

• Signs: fixed retroverted

uterus with posterior
tenderness, nodularities at
uterosacrals, endometrial
cysts
 Management of
Endometriosis

Management Goals:
1. Relief of pain
2. Promotion of fertility
 Management of
Endometriosis
Surgical Treatment

• Laparoscopy is for both

diagnostic and therapeutic
reasons
 Management of
Endometriosis
Surgical Treatment

• Conservative operations
include destruction of
implants, removal of
endometriosis, lysis of
adhesions and at times
presacral neurectomy
 Management of
Endometriosis
Surgical Treatment

• Hysterectomy with bilateral

removal of ovaries is last
resort for whom fertility is
not an issue
 Adenomyosis
• It is finding of endometrial
glands and stroma more
than one low-powered field
(2.5 mm) from the basalis
layer of the endometrium.
 Adenomyosis
• Most common is diffuse
involvement of both anterior
and posterior myometrium,
the latter being more
involved.
• The second presentation is
focal area or adenomyoma
 Adenomyosis
• Symptom consists of
dysmenorrhea and
menorrhagia.

• Pelvic findings is usually

diffuse symmetric
enlargement of the uterus,
2 to 3x normal size.
 Adenomyosis
• There is no satisfactory
medical treatment for their
disease.
• Hysterectomy is the
definitive treatment if
appropriate for woman’s
age, parity and plan for
future reproduction.
PREMENSTRUAL
TENSION
 PREMENSTRUAL
TENSION
• Premenstrual syndrome
occurs in 40% of women at
one time or another. It can be
severe and interferes with
work and personal
relationships.
 Definition of Terms
• PMS is defined as a group of
symptoms, both physical and
behavioral, that occur in the
second half of the menstrual
cycle, and that often interfere
with work and personal
relationships
 Symptoms of
Premenstrual Syndrome
1. Somatic symptoms
– Bloated feeling
– Feeling of weight increase
– Breast pain or tenderness
– Skin disorders
– Hot flushes
– Headache
– Pelvic pain
– Change in bowel habits
 Symptoms of Premenstrual
Syndrome
2. Psychologic symptoms
– Irritability
– Aggression
– Tension
– Anxiety
– Depression
– Lethargy
– Insomnia
– Change in appetite
– Crying
– Change in libido
– Thirst
– Lost of concentration
– Poor coordination, clumsiness,
accidents
 Diagnosis
• made by symptom diary and
elimination of other
diagnosis such as
psychiatric disorders like
depression, anxiety, and
psychosis. PMS patients
suffer their symptoms only
during the luteal phase
Management
1. Diet and exercise
– High protein, well
balanced diet with Vit B6
supplement (50 ng/day) is
recommended

2. Diuretics
– Potassium sparing diuretic
should be selected
Management
3. Progesterone
– Eg. Estradiol patches
(200ug every 3 days) and
norethisterone (5 mg day
19 to 26)

4. Psychotherapy
– Same responses as
placebo therapy
Management
5. Psychoactive drugs
– Effective in selected studies
– Eg. Alprazolam (Xanax) 0.25
mg BID days 20 to 28 with
one 0.25 mg dose on Day 1

6. Danazol
– May be effective at doses
200 mg QID days 20 to 28
Management
7. Bromocriptine
– 5 mg during luteal phase is
effective

8. NSAIDS
– May cause nonoliguric renal
failure

9. Hysterectomy with bilateral

oophorectomy
– Alternatives for severe cases
GOOD DAY!