MENSTRUAL

ABNORMALITIES

NORMAL MENSTRUATION

Menstruation
Menstruation, or period, is normal vaginal bleeding

that occurs as part of a woman's monthly cycle.

Every month, woman body prepares for pregnancy.
If no pregnancy occurs, the uterus, or womb, sheds
its lining.
The menstrual blood is partly blood and partly tissue
from inside the uterus.
It passes out of the body through the vagina

The Normal Menstrual Period

Blood loss 30 to 80 ml per cycle (average 30-

40 ml)
Duration of flow 3-7 days
days)
Cycle length 21 - 35 days
days)

(average 4
(average 29

(28 days +/- 7 days}

Normal menstrual cycle

The phase of the menstrual cycle & ovulation

regulates by:
interaction between hypothalamus, ptuitary
and ovaries
Mean age of menarche and menopase are:

Menarche 12,7
Menapause 51,4

Organs involved in menstrual cycle

Hipothalamus
Anterior Ptuitary
Ovary
Uterus (endometrium)

Hormones in menstrual
cycle
Gonadotrophin Releasing Hormone (GnRH)
Follicle Stimulating Hormone (FSH)
Lutenising Hormon (LH)
Estrogen
Progeterone

Phases of the Menstrual Cycle

Reproductive Cycle
Follicular
Begins with Menses ends with luteinizing (LH)
hormone surge
Ovulation (30-36 hours)
Begins with LH surge and ends with ovulation
Luteal (14 days)
Begins with the end of the LH surge and ends
with onset of menses

The Normal Menstrual Cycle

Another Way of looking at it

M. Manting; DUB LECTURE 2008

Phases of the Menstrual Cycle

Endometrium
Proliferative
Begins with menses and ends at ovulation

Secretory
Begins at ovulation and ends with menses

MENSTRUAL
ABNORMALITIES

Menorrhagia

Menorrhagia
Menorrhagia can be defined as a complaint

of
heavy cyclical menstrual blood loss over
several consecutive menstrual cycles in a
woman of reproductive years, or more
objectively, a total menstrual blood loss of
more than 80 ml per menstruation
(Hallberg et al, 1966).
Accompanied by other symptoms such as
menstrual pain (dysmenorrhoea)

Etiology
Hormonal disturbances, Ovarian dysfunction,

Uterine fibroids, Uterine polyps, Adenomyosis, Nonhormonal Intrauterine Device (IUD)

Pregnancy-related complications such as a
miscarriage or an ectopic pregnancy can cause
menorrhagia
Cancer such as uterine, cervical or ovarian cancer
Inherited bleeding disorders such as Von
Willebrand's disease or a platelet function disorder
Medications, such as anti-inflammatory and
anticoagulants
Other health conditions such as
pelvic inflammatory disease (PID), thyroid
disorders,endometriosis, and liver or kidney
disease.

Signs and symptoms of

menorrhagia
Heavy vaginal bleeding resulting in the

saturation of one or more sanitary pads or

tampons every hour for several hours
Menstrual flow or bleeding lasting more than
1 week
Passage of blood clots which are the size of a
quarter or larger

Signs and symptoms of

menorrhagia
inability to perform regular daily activities

because of the bleeding

Signs and symptoms of anemia which include
tiredness, fatigue and shortness of breath
Constant lower abdominal and pelvic pain.

Tests and diagnosis of

menorrhagia
Physical exam
Bleeding diary
Blood tests to evaluate for disorders such as

anemia, thyroid disease and clotting disorders

Pap Smear to evaluate for cervical infection,
inflamation, dysplasia and cancer
Endometrial biopsy to test the lining of the
uterus for cellular abnormalities and cancer

USG to evaluate the pelvic organs including the

uterus, ovaries and pelvis

Sonohysterogram, a procedure in which fluid is
instilled into the uterus and an ultrasound
evaluates the uterus for abnormalities
Hysteroscopy, a procedure in which a camera is
inserted into the uterus for evaluation of the lining
Dilation and curettage (D&C) is a procedure
generally completed in the operating room in
which the lining of the uterus is scraped and
evaluated for abnormalities.

Treatment of menorrhagia is dependent

on each woman's personal situation
and may include interventions such as:
Drug therapy
Surgery

Drug therapy
Iron supplementation to treat anemia
Non-steroidal anti-inflammatories (NSAIDs) to treat

dysmenorrhea (painful menstrual cramps) and aid

in blood loss reduction. NSAIDs include ibuprofen
(Advil, Motrin IB, others) or naproxen (Aleve).
Tranexamic acid (Lysteda), when taken at the time
of bleeding, is a medication which aids in the
reduction of blood loss
Oral contraceptives aid in menstrual cycle
regulation and decrease bleeding duration and
quantity

Oral Progesterone is used to treat hormonal

imbalance and decrease bleeding

Hormonal IUD thins the lining of the uterus
and decreases bleeding amount; it is also
beneficial in decreasing uterine cramping
Desmopressin nasal spray (Stimate) is used
in certain situations when bleeding disorders
such as von Willebrand's disease or mild
haemophilia are present to increase bloodclotting proteins

SURGERY
Non hysterectomy or interventional radiology
Endometrial abltion
Uterine artery embolitation
Hysteroscopic myomectomy
Hysterectomy

Hypomenorrhoea

Hypomenorrhoea
uterine bleeding of less than normal (less

than 30 ml per cycle)

the period of flow being of the same or
less than usual duration

Most often scanty bleeding is not a serious

medical condition, yet, it is important to

diagnose the underlying cause to avoid future
complications

What causes 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:

- excess release of a male hormone called

testosterone can contributes to the
Hypomenorrhea.
- Most often hypothyroidism causes
anovulation resulting in hypomenorrhea.

Uterine problems:

Thickness of the uterine lining or

endometrium determines the amount of blood
flow, insufficient thickness of uterine lining
causes scanty flow.
Malnutrition

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. Such mental state for a prolonged
period disturbs the pattern of blood flow. Stress
hormones block the release of the luteinizing
hormone; a precondition for normal bleeding

Diagnostic Tests And

Investigations
Blood tests are indicated in order to know

about the hormonal deficiencies like FSH, TSH,

LH, Estrogen, Progesterone, Androgens, and
Insulin etc. In Polycystic Ovarian Disease (one
of the cause of scanty menses), there would
be high level of insulin and Androgens.

Ultrasonograpy comes next in order to see

the lining of Uterus, Follicular development,

ovaries growth etc. D&C, MRI or Endometrial
biopsy is done in extreme cases where other
factors cant be isolated.

Therapy
As for as treatment ofHypomenorrheais

concerned, it depends upon the cause. Not in

every case, hormones can be given. Also the
hormonal therapy is a specific type of
treatment that can only be started under
doctor's observation and advice.

Polymenorrhea

Polymenorrhea
frequent menses
Uterine bleeding occurring at regular intervals

less than 21 days

Causes:
Short follicular phase
Inadequate luteal phase
Dysfunctional uterine bleeding

Oligomenorrhea &
Amenorrhea

Oligomenorrhea
reduction in frequency of menses
bleeding with menstrual intervals greater
than 35 days
Causes:
Menopause
OCP manipulation
Hypothalamic dysfunction
Chronic illness
Polycstic ovary

Amenorrhea
Amenorrhea absence of menses
Primary amenorrhea absence of menarche

Absence of menarche by age 14 without secondary

sexual characteristics
Absence of menarche by age 16 with secondary sexual
characteristics

Secondary amenorrhea absence of menses

in a previously menstruating woman

Absence of menses for > 6 months or duration of 3

menstrual cycles

Primary Amenorrhea: Etiology

Pregnancy
Thyroid disease
Hyperprolactinemia
Prolactinoma

Hypergonadotropic hypogonadism
Gonadal dysgenesis (i.e. Turner syndrome)
Premature ovarian failure

Hypogonadotropic hypogonadism
Constitutional delay of puberty
Congenital GnRH deficiency (Kallman syndrome)
Functional hypothalamic amenorrhea (i.e. Anorexia or Bulimia nervosa)
CNS tumor (i.e. Craniopharyngioma)

Normogonadotropic
Congenital (i.e. Mullerian agenesis, Androgen Insensitivity syndrome)
Outflow tract obstruction (i.e. Imperforate hymen, Transverse vaginal septum)
Hyperandrogenic anovulation (i.e. PCOS, Cushings disease)

Primary Amenorrhea: Etiology

Most common etiologies:
Chromosomal abnormalities causing gonadal

dysgenesis 50%
Hypothalamic hypogonadism 20%
Absence of the uterus, cervix, or vagina 15%
Transverse vaginal septum or imperforate hymen
5%
Pituitary disease 5%

Primary Amenorrhea: History

Findings

Association

Completion of stages of puberty?

Development of axillary and pubic hair?
Breast development?

Ovarian or pituitary failure

Chromosomal abnormality

Family history of delayed or absent puberty?

Familial disorder
Constitutional delay of puberty

Height relative to family members?

Turners syndrome

Symptoms of virilization?

PCOS
Ovarian or adrenal tumor
Presence of Y chromosome

Recent stress? Change in weight, diet, or

exercise?

Functional hypothalamic
amenorrhea

Medications (i.e. antidepressants,

antipsychotics)?

Hyperprolactinemia

Galactorrhea?

Hyperprolactinemia

Headaches, visual field defects, fatigue,

polyuria or polydipsia?

Hypothalamic-pituitary disease

Primary Amenorrhea: Physical Exam

Evaluation of pubertal development (height, weight) and

growth chart
Breast development (Tanner staging)
Evaluation for features of Turners syndrome
Webbed neck, low hair line, shield chest, widely spaced nipples

Examine skin for hirsutism, acne, striae, increased

pigmentation, and vitiligo

Pelvic exam
Clitoral size
Intactness of hymen
Depth of vagina
Presence of vaginal septum
Presence of cervix, uterus, and ovaries

Tanner Stages
Stage 1: Prepubertal,
no palpable breast
tissue or pubic hair.
Stage 2:
Development of
breast bud; sparse,
straight pubic hair.
Stage 3: Enlargement
of breast; pubic hair
darker, coarser, and
curlier.
Stage 4: Areola and
papilla project above
the breast; pubic hair
adult-like in
appearance.
Stage 5: Recession of
areola to match
contour of breast;
pubic hair extends to

Figure from: Roede, MJ, van Wieringen, JC. Growth diagrams 1980: Netherlands
third nation-wide survey. Tijdschr Soc Gezondheids 1985; 63:1. Reproduced with

Primary Amenorrhea: Evaluation

Secondary
Secondary sexual
sexual characteristics
characteristics
present?
present?
No
No

Yes
Yes
Perform
Perform ultrasound
ultrasound of
of
uterus
uterus

Measure
Measure FSH
FSH
FSH
FSH <
<
5
5

FSH
FSH >
>
20
20

Hypogonadotropi
Hypogonadotropi
c
c
hypogonadism
hypogonadism
Hypothalamic
Hypothalamic

Hypergonadotrop
Hypergonadotrop
ic
ic
hypogonadism
hypogonadism

amenorrhea
amenorrhea
Karyotype
Constitutional
Karyotype
Constitutional delay
delay
analysis
of
analysis
of puberty
puberty
Kallman
syndrome
Kallman syndrome
45,X
CNS
45,X
CNS tumor
tumor
46,XX
46,XX

O
O

Premature
Premature
ovarian
ovarian failure
failure

Turners
Turners
syndrome
syndrome

Uterus
Uterus
absent
absent or
or
abnormal
abnormal

Uterus
Uterus
present
present or
or
normal
normal

Karyotype
Karyotype
analysis
analysis
46,X
46,X
Y
Y

46,XX
46,XX

Androgen
Androgen
insensitivity
insensitivity
syndrome
syndrome

Mlleria
Mlleria
n
n
agenesi
agenesi
s
s

Outflow
Outflow
obstruction
obstruction
No
No

Yes
Yes
Imperforate
Imperforate

Evaluate
Evaluate for
for
hymen
hymen
2
amenorrhea
2
amenorrhea
Transverse
PCOS
Transverse vaginal
vaginal
PCOS
Cushing
Cushing
s
s

septum
septum

Secondary
Amenorrhea/Oligomenorrhea: Etiology
Pregnancy
Thyroid disease
Hyperprolactinemia
Prolactinoma
Breastfeeding, Breast stimulation
Medication (i.e. Antipsychotics, Antidepressants)

Hypergonadotropic hypogonadism
Postmenopausal ovarian failure
Premature ovarian failure

Hypogonadotropic hypogonadism
Functional hypothalamic amenorrhea (i.e. Anorexia or Bulimia nervosa)
CNS tumor (i.e. Craniopharyngioma)
Sheehans syndrome
Chronic illness

Normogonadotropic
Outflow tract obstruction (i.e. Ashermans syndrome, Cervical stenosis)
Hyperandrogenic anovulation (i.e. PCOS, Cushings disease, CAH)

Secondary
Amenorrhea/Oligomenorrhea: Etiology
Most common etiologies:
Ovarian disease 40%
Hypothalamic dysfunction 35%
Pituitary disease 19%
Uterine disease 5%
Other 1%

Secondary
Amenorrhea/Oligomenorrhea: History
Findings

Association

Recent stress? Change in weight, diet, or

exercise?

Functional hypothalamic
amenorrhea

Development of acne, hirsutism, striae,

central obesity, increased skin pigmentation
or deepening voice?

PCOS
Cushings disease
Ovarian or adrenal tumor

Medications (i.e. antidepressants,

antipsychotics)?

Hyperprolactinemia

Chronic illness?

Functional hypothalamic
amenorrhea

Headaches, visual field defects, fatigue,

polyuria or polydipsia?

Hypothalamic-pituitary disease

Symptoms of estrogen deficiency (hot

flashes, vaginal dryness, decreased libido, or
poor sleep)?

Premature ovarian failure

Postmenopausal ovarian failure

Galactorrhea?

Hyperprolactinemia

History of obstetrical catastrophe, severe

bleeding, D&C, endometritis, or other

Sheehans syndrome
Ashermans syndrome

Secondary
Amenorrhea/Oligomenorrhea: Physical
Exam
General
Evaluation of height, weight, and BMI
Examine skin for hirsutism, acne, striae, acanthosis nigricans,

thickness or thinness, and easy bruisability

Thyroid exam
Breast exam
Express for galactorrhea

Pelvic exam
Atrophy
Vaginal dryness

Secondary
Amenorrhea/Oligomenorrhea:
Evaluation
Negative
Negative urine
urine pregnancy
pregnancy test
test
Check
Check TSH
TSH and
and prolactin
prolactin
Normal
Normal
prolactin,
prolactin,
Abnormal
Abnormal TSH
TSH

Both
Both
normal
normal
Progestin
Progestin challenge
challenge
test
test
Withdrawal
Withdrawal
bleed
bleed

Thyroid
Thyroid
disease
disease

No
No withdrawal
withdrawal bleed
bleed

Normogonadotropic
Normogonadotropic
hypogonadism
hypogonadism

Normal
Normal TSH,
TSH,
Abnormal
Abnormal
prolactin
prolactin
Prolactin
Prolactin <
< 100
100
ng/mL
ng/mL

Prolactin
Prolactin >
> 100
100
ng/mL
ng/mL

Medication
Medication

MRI
MRI to
to evaluate
evaluate
for
for
prolactinoma
prolactinoma

Estrogen/progestin
Estrogen/progestin
Challenge
Challenge test
test

Hyperandrogeni
Hyperandrogeni
c
c anovulation
anovulation
No
PCOS
No withdrawal
withdrawal bleed
bleed
PCOS
Cushings
Cushings

Outflow
Outflow
Ashermans
obstruction
obstruction
Ashermans
Cervical
Cervical
stenosis
stenosis

Negative
Negative MRI
MRI
Consider
Consider
other
other causes
causes

Withdrawal
Withdrawal
bleed
bleed
Check
Check FSH
FSH

Medication
Medication

FSH
FSH >
> 20
20
IU/L
IU/L

Hypergonadotrp
Hypergonadotrp
oic
oic
hypogonadism
Ovarian
Ovarian
hypogonadism
failure
failure

FSH
FSH <
< 5IU/L
5IU/L

MRI
MRI to
to evaluate
evaluate
for
pituitary
for pituitary
tumor
tumor

Hypothalam
Hypothalam
Normal
Normal MRI
MRI
ic
ic
Hypogonadotr
Hypogonadotr amenorrhea
amenorrhea
opic
opic
Chronic
Chronic
hypogonadism
hypogonadism illness

Secondary
Amenorrhea/Oligomenorrhea:
Evaluation
Progestin challenge test
Medroxyprogesterone acetate 10 mg daily for 10 days
IF withdrawal bleed occurs Not outflow tract

obstruction
IF no withdrawal bleed occurs Estrogen/Progestin
challenge test

Estrogen/Progestin challenge test

Oral conjugated estrogen 0.625 2.5 mg daily for 35

days
Medroxyprogesterone acetate 10 mg daily for 26-35
days
IF no withdrawal bleed occurs Endometrial scarring

Secondary
Amenorrhea/Oligomenorrhea:
Evaluation
Evaluation of hyperandrogenism
Symptoms: hirsutism, acne, alopecia, masculinization, and

virilization
Differential diagnosis:
Adrenal disorders: Atypical congenital adrenal hyperplasia
(CAH), Cushings syndrome, Adrenal neoplasm
Ovarian disorders: PCOS, Ovarian neoplasms
Lab: Testosterone, DHEA-S, Indication
17-hydroxyprogesterone
Hormone
Level
Testosterone

DHEA-S

< 200
ng/dL

PCOS

> 200
ng/dL

Evaluate for adrenal or ovarian tumor

< 700
ng/dL

PCOS

> 700
ng/dL

Evaluate for adrenal or ovarian tumor

Amenorrhea/Oligomenorrhea:
Management
Treatment should be directed at
Correcting the underlying pathology
Helping woman to achieve fertility (IF desired)
Preventing the complications of disease process

Consequences of untreated

amenorrhea/oligomenorrhea:
Hypoestrogenism Osteoporosis, Infertility
Hyperestrogenism Heart disease, Stroke, Diabetes Mellitus,

Breast cancer (controversial), Endometrial hyperplasia and

Endometrial cancer

Amenorrhea/Oligomenorrhea:
Management
Diagnosis

Management

Ovarian insufficiency
Premature ovarian failure
Postmenopausal ovarian failure

Hormone replacement therapy (HRT)

*Congenital anatomic lesions

Surgical correction

*Presence of Y chromosome (i.e. AIS)

Gonadectomy

*Gonadal dysgenesis (i.e. Turner

syndrome)

Estrogen + progestin, growth hormone

IVF (IF pregnancy desired)

Hyperprolactinemia

Dopamine agonist (Bromocriptine, Cabergoline)

Functional hypothalamic amenorrhea

Increase caloric intake > energy expenditure

Hypothalamic or pituitary dysfunction

(non-reversible)

OCPs, pulsatile GnRH or exogenous

gonadotropins

CNS tumor
Craniopharyngioma
Prolactinoma

Surgical resection
Microadenoma (< 10mm) Dopamine agonist
Macroadenoma (>10mm) Trans-sphenoidal
resection

PCOS

OCPs, weight loss, and metformin

Ashermans syndrome

Hysteroscopic lysis of adhesions

*Causes of primary amenorrhea only

Dysmenorrhea

Dysmenorrhea

Dysmenorrhea
Dysmenorrhea severe, painful cramping

sensation in the lower abdomen often

accompanied by other symptoms
sweating, tachycardia, headaches, n/v,
diarrhea, tremulousness, all occurring just
before or during menses
- Primary: no obvious pathologic condition,
onset < 20 years old
- Secondary: associated with pelvic
conditions or pathology

Primary Dysmenorrhea
Pathogenesis: Dysmenorrhea is thought to be

caused by the release of prostaglandins in the

menstrual fluid, which causes uterine
contractions and pain.
Treatment: NSAIDs PG synthetase inhibitors
1st line treatment of choice
Other treatment options: OCPs (Oral
contraceptive pills), other analgesics

Secondary
Dysmenorrhea
Etiologies

Cervical Stenosis
Endometriosis and Adenomyosis
Pelvic Infection
Adhesions
Pelvic Congestion
Stress and Tension

Secondary
Dysmenorrhea
Cervical Stenosis

- Severe narrowing of cervical canal may

impede menstrual outflow congenital or
iatrogenic
- can cause an increase in intrauterine
pressure during menses
- can lead to endometriosis

Secondary
Dysmenorrhea
Cervical Stenosis

- Hx scant menstrual flow, severe cramping

throughout menses
- Dx inability to pass a thin probe through
the internal os OR HSG demonstrates thin cx
canal
- Tx cervical dilation via D&C or laminaria
placement

Secondary
Dysmenorrhea
Pelvic Congestion

- Due to engorgement of pelvic vasculature

- Hx burning or throbbing pain, worse at
night and after standing
- Dx Laparoscopic visualization of
engorgement/varicosities of broad ligament
and pelvic sidewall veins

PRE-MENSTRUAL
SYNDROME

WHAT IS PMS:
It is a disorder characterized

by a set of hormonal changes

that trigger disruptive
symptoms in women two
weeks prior to menstruation.

What causes PMS:

Too little progesterone in

comparison to the level of

estrogen is the cause of PMS.
This imbalance is from poor
ovulation or no ovulation or
stress causing the first two
conditions. Need to supplement
the progesterone level, relieve
stress, develop a healthier life

TYPES OF PMS:
PMS-A: Anxiety, nervous

tension, irritability, and mood

swings.
PMS-H: Hyper hydration,
water retention, abdominal
bloating, breast
tenderness,weight gain,
swelling of hands and feet.

Types continued:
PMS-C: Cravings, for sweets,

salty foods, increased

appetite, headaches, fainting
PMS-D: Depression,
confusion, fatigue, crying,
forgetfulness and insomnia.

PMS REPORTED BY WOMEN WHO :

Have had children

Had pregnancy complications

Report minor pain and

cramping with periods

Eat a high sugar and salt diet
Dont exercise regularly

CONTINUED:
High stress
After taking birth control or

HRT ( Hormone Replacement

Therapy)

DIET MAKES A
DIFFERENCE
ELIMINATE: Sugar, caffeine,

artificial sweetners, cigarettes

and alcohol.
EMPHASIZE: Whole grains,
dried beans, nuts, fresh
veggies and fruit.

DIET CONTINUED:
AVOID: Salty and smoked

foods, dairy products. If

bloating is a problem, limit
fruit and eliminate fruit juices.

Treatment:
1. Eat small frequent meals 6x a

day to avoid low blood sugar

levels.
2. Increase intake of fresh fruit
and veggies.
3. Decrease intake of fat, sugar,
salt, caffeine and red meat.
4. Exercise at least 20 minutes
3x/wk.

Continued:
5. Take PMS vitamins every

day
6. Try to relieve stress in your
life.
7. Stop Smoking!!!!

THANK YOU