MENSTRUAL

IRREGULARITIES
MENORRHAGIA (HYPERMENORRHEA)

-Cyclic bleeding at normal intervals; the

bleeding is either excessive in amount (> 80
mL) or duration (>7 days) or both.
-The term menotaxis is often used to denote
prolonged bleeding.
 CAUSES:

Organic and functional

Organic :
1.Pelvic
• Due to congestion, increased surface area, or
hyperplasia of the endometrium
- Fibroid uterus
- Adenomyosis
- Pelvic endometriosis
- IUCD in utero
2. Systemic
-Liver dysfunction -failure to conjugate and thereby
inactivates the estrogens.
-Congestive cardiac failure.
-Severe hypertension.
-Liver produces bile, aids in elimination as it carries
estrogen and other waste via dietary fiber
-If fiber isn’t available, the risk of toxic estrogen build up
is increased.
-Liver is overloaded and can’t fully metabolize estrogens
and toxins, the body may store them in fat.
-Fat cells also produce estrogen.
3. Endocrinal
-Hypothyroidism.
-Hyperthyroidism
4.Hematological
-Idiopathic thrombocytopenic purpura.
- Leukemia.
-Von Willebrand’s disease.
-Platelet deficiency.
5. Emotional upset
Functional
-Due to disturbed hypothalamo-pituitary-
ovarian-endometrial axis.
 DIAGNOSIS

Long duration of flow, passage of big clots, use of

increased number of thick sanitary pads, pallor, and low
level of hemoglobin
 TREATMENT

The definitive treatment is appropriate to

the cause for menorrhagia.
 POLYMENORRHEA
( EPIMENORRHEA)

-Cyclic bleeding where the cycle is reduced to an

arbitrary limit of less than 21 days and remains
constant at that frequency.
- If the frequent cycle is associated with excessive
and or prolonged bleeding, it is called
Epimenorrhagia
 CAUSES

Dysfunctional:
-Predominantly during adolescence, preceding
menopause and following delivery and abortion.
-Hyperstimulation of the ovary by the pituitary
hormones
-Ovarian hyperemia as in PID or ovarian
endometriosis.
 TREATMENT

-Persistent dysfunctional type is to be

treated by hormone as in DUB
 METRORRHAGIA

-Irregular,
acyclic bleeding from the uterus.
-Amount of bleeding is variable.
-Bleeding from any part of the genital tract, contact
bleeding or intermenstrual bleeding.
 CAUSES OF ACYCLIC BLEEDING

-During adolescence, following childbirth and

abortion and preceding menopause
-Submucous fibroid
-Uterine polyp
-Carcinoma cervix
-Endometrial carcinoma
 CAUSES OF CONTACT
BLEEDING

-Carcinoma cervix
-Mucos polyp of cervix
-Vascular ectopy of the cervix
-Infections
-Cervical endometriosis
 CAUSES OF INTERMENSTRUAL
BLEEDING

• Urethral caruncle
• Ovular bleeding
• IUCD in utero
• Decubitus ulcer
-Menometrorrhagia is the term when the bleeding
is so irregular and excessive that the menses cannot
be identified at all.
-Treatment is directed to the underlying pathology.
-Malignancy is to be excluded prior to any
definitive treatment.
 OLIGOMENORRHEA

Menstrual bleeding occurring more than 35 days

apart and which remains constant at that frequency
is called oligomenorrhea.
 CAUSES

-Age-related :during adolescence and

preceding menopause
-Weight-related :obesity
-Stress and exercise related
-Endocrine disorders : PCOS, hyperprolactinemia,
hyperthyroidism
-Androgen producing tumors : ovarian, adrenal
-Tubercular endometritis
-Drugs: • Phenothiazines • Cimetidine • Methyldopa
 HYPOMENORRHEA

-When the menstrual bleeding is unduly

scanty and lasts for less than 2 days, it is
called hypomenorrhea.
 CAUSES

Local (uterine synechiae or endometrial

tuberculosis) endocrinal (use of oral
contraceptives, thyroid dysfunction and
premenopausal period) or systemic
(malnutrition)
 DYSFUNCTIONAL UTERINE BLEEDING [DUB]

-State of abnormal uterine bleeding without any clinically

detectable organic, systemic, and iatrogenic cause (Pelvic
pathology, e.g. tumor, inflammation or pregnancy is
excluded).
-Heavy menstrual bleeding (HMB) is defined as a
bleeding that interferes with woman's physical,
emotional, social and maternal quality of life.
 INCIDENCE

10 percent amongst new patients attending

the outpatient
 PATHOPHYSIOLOGY
Physiological mechanism of hemostasis in normal
menstruation are:
(1) Platelet adhesion formation.
(2) Formation of platelet plug with fibrin to seal the
bleeding vessels.
(3) Localized vasoconstriction.
(4) Regeneration of endometrium.
(5) Biochemical mechanism involved are:
-Increased endometrial ratio of PGF2α/PGE2.
-PGF2α causes vasoconstriction and reduces
bleeding.
-Progesterone increases the level of PGF2α from
arachidonic acid.
-Endothelin, powerful vasoconstrictor also
increased.
-Endometrial abnormalities may be in coordination
with hypothalamo pituitary-ovarian axis.
-Reproductive period : adolescence and
premenopause or following childbirth and abortion.
-Emotional influences, worries, anxieties, or sexual
problems disturb the normal hormonal balance.
Abnormal bleeding may be associated with
or without ovulation and accordingly
grouped into :
- Ovular bleeding
-Anovular bleeding
 OVULAR BLEEDING

Polymenorrhea or polymenorrhagia:
-Following childbirth and abortion, during
adolescence and premenopausal period, and in PID
-Follicular development is speeded up with
resulting shortening of the follicular phase.
-Luteal phase shortened due to premature lysis
of the corpus luteum.
-Endometrial study prior to or within few
hours of menstruation reveals secretory
changes.
Oligomenorrhea:
-Met in adolescence and preceding
menopause.
-Undue prolongation of the proliferative phase with
normal secretory phase.
-Endometrial study prior to or within few hours of
menstruation reveals secretory changes.
Functional menorrhagia:
- Irregular shedding of the endometrium.
- Irregular ripening of the endometrium.
Irregular shedding of the endometrium
-Reproductive period.
-Desquamation for a variable period with
simultaneous failure of regeneration of the
endometrium.
Irregular ripening of the endometrium
-Poor formation and inadequate function of the
corpus luteum.
-Secretion of both estrogen and progesterone is
inadequate to support the endometrial growth.
 ANOVULAR BLEEDING

Menorrhagia
-In the absence of progesterone due to anovulation, the
endometrial growth is under the influence of estrogen
throughout the cycle.
-Inadequate structural stromal support and the
endometrium remains fragile.
-Withdrawal of estrogen due to negative feedback action
of FSH, the endometrial shedding continues for a longer
period.
Cystic glandular hyperplasia ( Metropathia
hemorrhagica, Schroeder’s disease)
-Met in premenopausal women.
 As there is no ovulation, the endometrium
is under the influence of estrogen without
being opposed by growth limiting
progesterone for a prolonged period
-Due to increased endometrial thickness, tissue
breakdown continues for a long time.
-Bleeding is heavy as there is no vasoconstrictor
effect of PGF2α.
-Bleeding is prolonged until the endometrium and
blood vessels regenerate to control it.
 Changes in the
uterus:
On naked eye examination, the
-
endometrium looks thick, congested and
often polypoidal
Microscopically
(a) Marked hyperplasia of endometrial
components. Some are small, others are large
giving the appearance of “Swiss cheese” pattern.
The glands are empty and lined by columnar
epithelium.
 (b) Absence of secretory changes.
(c) Areas of necrosis in the
superficial layers with small hemorrhages
and leukocytic infiltration.
 Changes in the ovary:

-Cystic changes observed one or both the ovaries.

-Single or multiple and fluid contains estrogen.
-Follicular type.
-No evidence of corpus luteum.
 INVESTIGATIONS

-History: bleeding through vagina and not

from the urethra or rectum.
-Number of pads used, passage of clots and
duration of bleeding.
-Hemoglobin percentage
-Cyclic or acyclic, its relation to puberty, pregnancy
events and last normal cycle.
-Emotional upset or psychosexual problem.
-Steroidal contraceptives or IUCD insertion
-Injury site, epistaxis, gum bleeding, or PID
-Internal examination:
-Bimanual examination including speculum examination in all
cases except virgins, rectal examination to exclude pelvic
pathology.
-Vaginal examination in virgins under general anesthesia with
endometrial curettage.
 Special investigations

-Platelet count, Prothrombin time, Bleeding

time, Partial thromboplastin time
-Serum TSH, T3, and T4 estimation
-Ultrasound and Color Doppler
-Transvaginal sonography
-SalineInfusion Sonography (SIS)
-Hysteroscopy
-Hysteroscopy and directed biopsy (H and B)
-Endometrial sampling
-Pipelle sampler.
-Laparoscopy
-Diagnostic uterine curettage
*Organic lesions in the endometrium
*Functional state of the endometrium.
*Incidental therapeutic benefit.
 MANAGEMENT

Reproductive period
1. General
2. Medical
3. Surgery
1.General
-Rest and assurance
-Anemia corrected by diet, hematinics, and blood
transfusion.
-Systemic or endocrinal abnormalities be investigated and
treated
 2. Medical management

1. Hormones:
a. Progestins:
-Norethisterone acetate and Medroxyprogesterone acetate
- Stimulates the enzyme (17-β-hydroxy steroid
dehydrogenase) converts estradiol to estrone.
- Inhibits induction of estrogen receptor.
- Antimitotic effect on the endometrium.
-While isolated progestins therapy is highly
effective in anovular DUB, in ovular DUB
combined preparations of progestogen and estrogen
are effective.
Preparation used are:
-Cyclic therapy
-Continuous therapy
-To stop bleeding and regulate the cycle
-Norethisterone preparations (5 mg tab) thrice
daily till bleeding stops.
-Cyclic Therapy
*5th–25th day course
*15th–25th day course.
 ``3
*5th to 25th day course:
-In ovular bleeding:
-3 consecutive cycles.
-Suppress the hypothalamopituitary axis
-Normal menstruation is expected to resume with restoration of
normally functionating pituitary–ovarian-endometrial axis.
-Reduces menstrual blood loss by 50%
-Serves as a contraceptive
 `

-In anovular bleeding:

Medroxyprogesterone acetate (MPA) 10 mg or
Norethisterone 5 mg is used from 5th to 25th
day of cycle for 3 cycles.
*15th to 25th day course:
-In ovular bleeding, patient wants pregnancy,
Dydrogesterone 10 mg twice a day
-Adolescent anovulatory women have immaturity of H-
P-O axis.
-Ideal for use of short-term cyclic therapy until the
maturity of the positive feedback system is established
-Continuous progestins:
-Inhibit pituitary gonadotropin secretion and ovarian hormone production.
-Medroxyprogesterone acetate 10 mg thrice daily and continued for at
least 90 days.
-Oral , long-acting IM injections, DMPA implants, Progestogen only pill
to reduce menstrual blood loss.
-Helps organized endometrial shedding upto the basal layer and increases
the endometrial ratio of PGF2α/PGE2 and thromboxane .
b. Intrauterine progestogen:
- LNG-IUS induce endometrial glandular atrophy, stromal
decidualization and endometrial cell inactivation .
-Effective for 5 years.
-Minimal systemic absorption.
- Reduction of blood loss is upto 97 % is considered as
medical hysterectomy.
Normally small compact cells of the
endometrial stroma undergo remarkable enlargement; this
process is known as decidualization
-Effective contraceptive measure.
-First line therapy for a woman with HMB
in the absence of any structural or
histological abnormality
c. Danazol
-Recurrent symptoms and patients for
hysterectomy.
-200–400 mg daily in 4 divided doses for 3
months.
d.Mifepristone (RU 486):
-Progesterone receptor modulator
-Inhibits ovulation and induces amenorrhea
and reduces myoma size .
e.GnRH agonists:
-Subtherapeutic doses reduce the blood loss whereas in
therapeutic doses produce amenorrhea.
-Short-term use, if the woman is infertile and wants pregnancy.
-SC or Intranasally.
-Improves anemia and used before endometrial ablation.
2.Non-hormonal management
a. Anti-fibrinolytic agents (Tranexamic acid) reduces menstrual
blood loss by 50%.
-Counteracts endometrial fibrinolytic system.
-Gastrointestinal side effects
-Second line therapy.
b. Prostaglandin synthetase inhibitors:
-Mefenamic acid in women aged more than 35 years and
ovulatory DUB.
- 150–600 mg orally in divided doses during the bleeding phase.
-Inhibit synthesis of prostaglandins.
-Reduce menstrual blood loss by 25–40%.
-Improvement of dysmenorrhea, headache or nausea
c. Desmopressin:
-Synthetic analogue of arginine-vasopressin.
-Von Willebrand’s disease and factor VIII
deficiency.
- IV (0.3 µg/kg) or intranasally.
 3. Surgical management

1.Uterine curettage
2.Endometrial ablation/resection
3.Hysterectomy
1. Uterine Curettage
-Hemostatic and therapeutic effect by removing
necrosed and unhealthy endometrium.
- Following USG for endometrial pathology.
- Hysteroscopy and directed biopsy considered both
for diagnosis and therapy.
2. Endometrial Ablation/Resection
- Failed medical treatment
- Do not wish to preserve menstrual or reproductive function
- Uterus normal size or not bigger than 10 weeks pregnancy size
- Small uterine fibroids (< 3 cm)
- Avoid longer surgery
- Preserve her uterus.
a. Laser ablation of the endometrium
-Using Nd : YAG laser through hysteroscope is an
alternative to hysterectomy.
-Tissue destruction (coagulation, vaporization, and
carbonization) to a depth of 4-5 mm produces a
therapeutic Ashermann’s syndrome and amenorrhea.
-Completed their families.
• Nd:YAG (neodymium-doped yttrium aluminium
garnet) is a crystal that is used as a laser medium
for solid-state lasers.
• Lasers work by emitting a wavelength of high
energy light, which when focused on a certain skin
condition will create heat and destroy diseased
cells.
b. Uterine thermal balloon
-Endometrium is destroyed using a thermal balloon with
hot normal saline (87°C) for 8–10 minutes.
-No dilatation of the cervical canal is needed.
-Not suitable for general anesthetic or long duration
surgery.
-Success rate is similar to TCRE.
-First line therapy and is done as a day care basis
c. Microwave endometrial ablation
-Outpatient procedure.
-Endometrial tissue upto a depth of 6 mm is ablated.
-Temperature in the region is 75–80°C.
-Treatment time (2–3 minutes) is less compared to TCRE.
-Results are similar to TCRE.
d. Novasure:
-Endometrial ablation is done using a bipolar radio frequency
mounted on an expandable frame.
-Creates a confluent lesion on the entire endometrial surface.
-Time required for global endometrial ablation is 90 seconds
-Radio frequency energy vaporizes or coagulates the
endometrium up to the myometrium.
-Women with uterine cavity < 4 cm, PID, cesarean delivery are
contraindicated.
e. Transcervical resection of the endometrium (TCRE)
-Continuous flow resectoscope is quicker than laser
ablation.
-Under paracervical block.
-Resectoscope loop must remove the basal layer of
endometrium along with superficial layer of myometrium
f. Roller ball ablation of endometrium is also
effective.
- It coagulates endometrium up to a depth of about
4 mm.
Complications
-Infection
-Uterine perforations
-Fluid absorption may occur during hysteroscopic
procedure.
g. Uterine artery embolization
-In women with large uterine fibroid (> 3 cm) with
heavy bleeding.
-Particles are injected to block uterine artery under
local anesthesia.
- Shrinks fibroids.
3. Hysterectomy
-Not recommended as a first line therapy for heavy
menstrual bleeding (HMB) or DUB.
-When the conservative treatment fails or
contraindicated and the blood loss impairs the
health.
-Endometrial hyperplasia and atypia is an indication for
hysterectomy.
-Patient is approaching 40.
- Factors to consider are: uterine size, mobility, descent, previous
surgery, and presence of comorbidities.
-Healthy ovaries be preserved those under 45 years of age.