Menstrual Disorders

DR TAN THIAM CHYE Consultant Dept of Obstetrics and Gynaecology Assistant Professor Duke-NUS Graduate Medical School YLL School of Medicine, NUS

PRIMARY AMENORRHOEA
Definition Never experienced menstrual period by age 16

Primary amenorrhoea
Constitutional delay Similar history in mother or sisters

Primary ovarian failure Could be due to chemotherapy or radiotherapy Chromosomal disorders Developmental disorders

Chronic systemic diseases Eg diabetes mellitus, renal disease XY female

Turner syndrome 45, X0 Vaginal agenesis

Swyer syndrome 46 XY karyotype Pure gonadal dysgenesis No androgens or Mullerian inhibitory factors Allows Mullerian duct to develop into fallopian tubes, uterus and upper vagina

Complete androgen insensitivity syndrome 46 XY karyotype Phenotypically female Tall with good breast development Normal female external genitalia Sparse pubic and axillary hair No uterus and upper vagina

Rokitansky-Kuster Hauser syndrome Failure of Mullerian duct development Congenital absence of uterus and upper vagina Normal 46 XX karyotype

Management
Refer OBGYN for investigations and management of primary amenorrhoea For constitutional delay, no treatment is needed except reassurance For chromosomal disorders and primary ovarian failure, small dose of ethinyl oestradiol 1g daily can be started for 6 months, increasing to 2, 5, 10 and eventually 20 g with increments at six monthly intervals. This is then followed by combined oral contraceptive pills. For vaginal and mullerian agenesis, vaginal reconstruction is necessary. This could be achieved by vaginal dilators or surgical procedures like Williams vulvo-vaginoplasty, McIndoes procedure or skin graft. For the XY female, counseling with the parents is important to discuss on psychological issues of gender of rearing and gender identity. Management includes gonadectomy as the dysgenetic testes have a high lifetime risk of malignancy (30%).

SECONDARY AMENORRHOEA
DEFINITION
Cessation of menses for 6 months

Secondary amenorrhoea Hyperthyroidism Pregnancy

Hypothalamic dysfunction

Ovarian dysfunction Pituitary dysfunction

Resistant ovary syndrome

Extreme weight gain/ loss Excessive exercise

Prolactinoma (commonest) Sheehan syndrome Pituitary adenoma Craniopharyngioma

Polycystic ovarian syndrome (PCOS) Menopause Premature ovarian failure < 40 years old

Evaluation: History
Weight loss or gain, Psychological dysfunction/ emotional stress Presence of galactorrhoea Symptoms of thyroid disorder Hirsutism, change of voice, Menopausal symptoms Family history of possible genetic anomalies History of uterine/cervical surgery/ medication Sexual/contraceptive practice

Investigations:
1. Urine pregnancy test to exclude pregnancy 2. Follicular stimulating hormone (FSH) on Day 2-3 of menses
Suggests ovarian failure if > 30 IU/L Low level suggests hypothalamic/ pituitary dysfunction Reversal of LH/FSH ratio > 3:1 suggests PCOS

. Serum prolactin level

Hyperprolactinaemia could cause secondary amenorrhoea

.Thyroid function test

Hyperthyroidism could cause secondary amenorrhoea

. Progestogen challenge test

Give 5mg oral norethisterone bd for 5 days If there is withdrawal bleeding, there is presence of oestrogen and would mean that the patient would need cyclical progestogen for withdrawal bleeding to protect the endometrium from endometrial hyperplasia and carcinoma If there is no withdrawal bleeding, then combined oral contraceptive pill would be needed

DYSFUN CTI ON AL UTERI NE BLEEDI N G

De finition The norm m al enstrual cycle lasts between 21 and 35 days with m enstrual flow lasting 2-7 days. Any disturbance in the m enstrual cycle or flow pattern is term as dysfunctional ed uterine bleeding (DUB) after excluding system and pelvic pathological causes. ic Ste in workup of DUB ps (1) Look for pallor. If pale, check haem oglobin level. (2) Ensure that the patient is haem odynam ically stable. Quantify severity of bleeding eg. num of pads used / day and presence of blood clots or episodes ber of flooding (3) Clinical exam ination to exclude cervical lesion and do a PAP sm if last PAP ear sm > year ago ear 1

INVESTIGATIONS
Perform urine pregnancy test to exclude pregnancy related problems (threatened miscarriage, inevitable miscarriage or ectopic pregnancy) If there are bleeding tendencies, exclude blood dyscrasias for adolescents (13-18 years old) If there are symptoms of thyroid disorder or galactorrhoea, check thyroid function test or prolactin level Perform pelvic ultrasound scan to exclude pelvic pathology (fibroids/ adenomyosis) Perform endometrial assessment (if 40 years old or failed conventional medical treatment) to exclude endometrial hyperplasia or carcinoma

Goals of R x

Alleviate acute bleeding. Give IM progesterone 100 mg stat Prevent future episodes of noncyclic bleeding aim to give a bleed which is predictable in timing and amount Decrease risk of long term complications (eg development of endometrial cancer)
Common medical treatments Cyclic progestogen (at least 10-14 days per cycle) NSAIDs (eg mefenamic acid 500mg tds)
Norethisterone 5-10mg bd Provera 10mg bd

Antifibrinolytic agents eg Tranexamic acid (500mg-1g tds)

-can cause venous thrombosis

Combined oestrogen and progestogen preparation

Combined oral contraceptive pill Progyluton (containing 11 tabs of estradiol valerate 2 mg each and 10 tabs of 2mg estradiol valerate and 0.5mg norgestrel each)

Re r OBGYN for endometrial assessm and further treatment if failed fe ent conventional initial treatm or age 40 and above ent

OOther hormonal medical treatments MIRENA/ Levonorgestrel (LNG)-releasing Intrauterine System Releases 20ug of LNG daily which affects the endometrium locally Lasts 5 years Low local hormonal effect in the endometrium which provides shorter and lighter menses and reduces dysmenorrhea 20% amenorrhoea after 1 year 20% intermittent per-vaginal spotting in 1st 6 months Lower risks of pelvic inflammatory disease and ectopic pregnancy compared with copper-IUCD

PROGYLUTON
Cyclical sequential combined hormonal replacement therapy with 2mg estradiol valerate for first 11 days and 2mg estradiol valerate with 0.5mg norgestrel for next 10 days Regulates menstrual cycle and does not affect endogenous hormone production Does not interfere with ovulation Can be used by pre- and peri- menopausal patients

Depot Provera
Intramuscular Depot Provera 150mg every 3 monthly Induce endometrial atrophy and amenorrhoea Irregular bleeding in first 3 months Side-effects: abdominal bloating, breast tenderness, weight gain, depression, water retention

Gonadotrophin Releasing Hormone analogue (GnRHa)

Continuous treatment with GnRHa causes down-regulation of pituitary gland and subsequent decrease in gonadotrophins and ovarian steroids Causes amenorrhoea (90%) Side-effects are related to hypo-oestrogenism and post-menopausal in type (hot flushes, insomnia, mood swings) Not recommended for more than 6 months of continuous usage due to the risk of osteoporosis unless with hormonal add-back therapy Subcutaneous injection Zoladex (Goserelin) 3.6mg monthly, subcutaneous injection Lucrin (Leuprorelin) 3.75mg monthly / 11.25mg every 3-monthly, intra-muscular injection Decapetyl (Triptorelin) 3.75mg monthly

Danazol
Induce amenorrhoea in majority if taken in moderate/ high dose (> 400 mg daily) If taken at low dose (200 - 400 mg daily) it will induce amenorrhoea in some while others may experience light but often unpredictable bleed Masculinising side-effects such as hirsutism, acne, voice change (irreversible)

Surgical Management

Endometrial ablation

Hysterectomy

DEPOT PROVERA RELATED MENSTRUAL PROBLEMS

Amenorrhoea with Depot Provera

Perform urine pregnancy test to exclude pregnancy

Positive

Negativee

Manage pregnancy accordingly

Reassure as 50% of women have amenorrhoea while on Depot Provera

DEPOT PROVERA RELATED MENSTRUAL PROBLEMS

Irregular menses with Depot Provera

Perform urine pregnancy test to exclude pregnancy

Manage pregnancy accordingly

Positive

Negative

Bleeding 6 months

Bleeding > 6 months

Reassure as it is common in 35% of women on Depot Provera

NSAIDs (eg mefenamic acid 500mg tds x 10 days)

Conjugated oestrogen (Premarin) 0.625 mg OM x 21 days

Case 1
LMP: Cannot remember Clinically stable parameters UPT positive POC seen at cervical os

Pelvic scan: Empty uterus. ET 9 mm Adnexae NAD

Case 1
Diagnosis: Complete miscarriage Conservative management Oral augmentin x 1 week

Case 2
27 years old. 1 X LSCS for CPD (2002). 1 X m/c (2003) evacuation done. LMP 31/12/05 & p/v bleeding since then. Was treated as DUB on 23/01/06 in OPD. NE & Folic acid was given. Fybogel & enema x1. Presented to 24 hrs clinic on 24 Jan2006 at 1.10am.

Presenting Complaints
Prolonged PV bleeding
Since 31/12/05. 2 pads / day No signs of anemia.

LIF pain X 1 day

UPT +

Initial Assessment
In 24 hour Clinic
1. 2. HR 97 bpm; BP 95/63, Pain score 5/10 Abdomen soft but guarded in LIF; With lower abdominal fullness. No rebound. 3. VE left adnexal tenderness; No cervical excitation.

Urgent DI Scan
Mass at left adnexa, adjacent to left ovary (visualised) ring like, vascular. ? Ectopic Pregnancy Hemoperitoneum Empty uterus except for blood clots

In the Ward
Hb 13.4g/dl; BHCG 387.8IU/L. Patient and husband counseled on the high possibility of an ectopic pregnancy Agreeable for Laparoscopic salpingectomy KIV cystectomy KIV evacuation of uterus/ KIV laparotomy. Risks of op explained.

Operative findings
Haemoperitoneum 200 mls Ruptured left tubal ectopic pregnancy 4cm MIS Left salpingectomy done Left ovary normal,right tube normal