Disorders of Menstruation

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      • Polymenorrhea
        • Uterine bleeding occurring at regular intervals of < 21 days. (MCQ)
      • Menorrhagia
        • Prolonged (> 7 days) or excessive (> 80 mL) uterine bleeding occurring at regular intervals (MCQ)
      • Oligomenorrhea:
        • Uterine bleeding occurring at intervals > 35 days. (MCQ)
      • Metrorrhagia:
        • Bleeding occurring at frequent, irregular intervals.
      • Dysfunctional uterine bleeding:
        • Bleeding that occurs after organic, systemic, and iatrogenic causes have been ruled out
        • Two types anovulatory and ovulatory.
      • Abnormal uterine bleeding: reproductive age
        • A normal menstrual cycle occurs every 21–35 days (28 ± 7 days) with menstruation for 2–7 days. (MCQ)
        • The normal blood loss is less than 80 mL total (average 35 cc), which represents 8 or fewer soaked pads per day with usually no more than 2 heavy days(MCQ)
        • Etiology
          • Organic: Reproductive tract disease.
          • Accidents of pregnancy
            • threatened, incomplete,
            • missed abortion; ectopic pregnancy
            • trophoblastic disease
          • Malignancy:
            • Most commonly endometrial and cervical cancers(MCQ)
            • Estrogen producing ovarian tumors like the granulosa-theca cell tumors may present with excessive uterine bleeding. (MCQ)
          • Infection:
            • Endometritis presents with episodic intermenstrual spotting.
            • Cervicitis and severe vaginal infections can present with bleeding.
          • Structural causes : fibroids, polyps, adenomyosis
          • Foreign bodies:
            • Tampons retained in the vagina
            • intrauterine devices for contraception can cause bleeding.
          • Endometriosis: Occasionally presents as premenstrual spotting.
          • Traumatic vaginal lesions.
          • Systemic:
            • von Willebrand disease can cause bleeding due to coagulopathy.
            • Prothrombin deficiency. , Leukemia. , Sepsis.
            • Idiopathic thrombocytopenic purpura. , Hypersplenism.
            • Thyroid dysfunction:
              • Hypothyroidism causes anovulation and is frequently associated with menorrhagia and intermenstrual bleeding.
              • Cirrhosis:
                • Excessive bleeding secondary to the reduced capacity of the liver to metabolize estrogens.
          • Iatrogenic:
            • Anticoagulation medications.
            • Oral or injectable steroids used for contraception.
            • Hormone replacement therapy (HRT).
            • Tranquilizers and psychotropic drugs: (MCQ)
              • Interfere with neurotransmitters responsible for inhibition and release of hypothalamic hormones, leading to anovulation and AUB.
      • Dysfunctional uterine bleeding (DUB):
        • Ovulatory:
          • After adolescence and before perimenopausal years.
          • Usually menorrhagia and/or intermenstrual bleeding.
          • Due to abnormal endometrial hemostasis for any reason.
          • The diagnosis of ovulatory DUB is made by endometrial biopsy (EMB). (MCQ)
            • On the fourth day of flow, the EMB reveals both proliferative and secretory endometrium. (MCQ)
        • Anovulatory:
          • Predominant cause of DUB.
          • There is continuous estradiol production without corpus luteum formation or progesterone production.
          • This steady state of estrogen stimulation results in constant endometrial proliferation without progesterone-mediated maturation and shedding.
          • Fragments of overgrown endometrium sheds sporadically
          • Anovulation can manifest in:
            • Polycystic ovarian syndrome (PCOS).
            • Obesity.
            • Adolescents (perimenarchal).
            • Perimenopause.
      • Diagnostic tests
        • Pap smear.
        • Pregnancy test: Sensitive hCG.
        • Hemoglobin, serum Fe, serum ferritin.
        • TSH ,FSH.Prolactin.
        • Coagulation panel:
        • von Willebrand factor for adolescents with menorrhagia.
        • EMB for women ³ 35 yrs of age or with history of unopposed estrogen. (MCQ)
        • Pelvic ultrasound.
        • Sonohysterogram
          • pelvic US combined with intrauterine saline infusion to outline the uterine cavity
        • Hysteroscopy
      • Treatment
        • Treat organic, systemic, iatrogenic causes
        • Medical management:
          • First-line treatment
          • Used for women
            • who desire future fertility
            • those who will reach menopause within a short period of time.
          • NSAIDs(MCQ)
            • tranexamic acid/mefenamic acid
          • Iron supplements.
          • Hormones:
            • OCP is the mainstay for anovulatory bleeding. (MCQ)
            • Combination pill or estrogens are used in the acute management of DUB(MCQ)
            • Progestin intrauterine device (IUD) can be used for DUB. (MCQ)
        • D&C:
          • Indicated mainly for women with heavy bleeding leading to hemodynamic instability(MCQ)
          • Once the acute episode of bleeding is controlled, the patient can be placed on medical management. (MCQ)
        • Endometrial ablation:
          • Used as an alternative to hysterectomy when other medical modalities fail or when there are contraindications to their use.
          • It should not be used in women who wish to maintain their reproductive capacity. (MCQ)
        • Myomectomy.
        • Hysterectomy:
          • Reserved for women with other indications for hysterectomy, such as leiomyomas or uterine prolapse. (MCQ)
          • Hysterectomy should be used to treat persistent ovulatory DUB only after all medical therapy has failed. (MCQ)
      • Postmenopausal bleeding
        • defined as bleeding that occurs after 1 year of amenorrhea.
        • All vaginal bleeding in postmenopausal women must be evaluated
        • Etiology
        • Vaginal/endometrial atrophy
          • most common cause(MCQ)
          • Hypoestrogenism causes atrophy of the endometrium and vagina.
          • In the uterus, the collapsed, atrophic endometrial surfaces contain little or no fluid to prevent intra- cavitary friction.
          • This results in microerosions of the surface epithelium which is prone to light bleeding or spotting.
        • Postmenopausal HRT: (MCQ)
          • Many postmenopausal women who take HRT develop vaginal bleeding
        • Endometrial hyperplasia:
          • Endogenous estrogen production from ovarian or adrenal tumors
          • exogenous estrogen therapy
          • Obese women have high levels of endogenous estrogen due to the conversion of androstenedione to estrone and the aromatization of androgens to estradiol, both of which occur in peripheral adipose tis- sue. (MCQ)
        • Adenomyosis
          • Confirmed by pathologic examination following hysterectomy.
          • Symptomatic adenomyosis occurs after menopause only in the presence of postmenopausal HRT.
        • Post radiation therapy
          • A late effect of radiation therapy.
          • Radiation devascularizes tissue, causes sloughing, and bleeding.
          • Vaginal vault necrosis causes uncontrolled bleeding and pain.
        • Iatrogenic anticoagulant effect.
        • Neoplasia:
          • Endometrial cancer.
          • Cervical cancer.
            • Vaginal bleeding occurs because the cancer outgrows its blood supply.
            • The necrotic and denuded tissue bleeds easily and causes a malodorous discharge.
          • Vulvar cancer.
          • Estrogen-secreting ovarian tumor.
          • Leiomyomata uteri. (MCQ)
            • The diagnosis of a uterine sarcoma should be considered in postmenopausal women with rapidly growing leiomyomata.
          • Polyps:
            • Endometrial growths of unknown etiology.
            • Growth of polyps can be stimulated by estrogen therapy or tamoxifen. (MCQ)
            • They may be benign, premalignant, or malignant.
        • Infection: Uncommon cause of postmenopausal bleeding.
        • Trauma.
      • Studies
        • Vaginal probes and wet mount for infections.
        • Pap smear for cervical dysplasia, neoplasia.
        • Endometrial biopsy for endometrial hyperplasia or cancer.
        • Transvaginal ultrasound to assess endometrial stripe.
          • If endometrial stripe is < 4 mm, endometrial sampling may be deffered unless the patient has persistent bleeding. (MCQ)
            • Rationale is thin lining due to atrophy. (MCQ)
        • Diagnostic D&C.
        • Hysteroscopy.
      • Treatment of postmenopausal bleeding
        • It is dependent on the cause:
        • Local estrogen cream is used to treat vaginal atrophy and postradiation effect limited to the vaginal region.


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