Menarche to Menopause

DR.DIVYA JAIN

INDORE

Menstruation Shedding the uterine lining

(endometrium) if pregnancy does not occur.

Necessary (in the absence of hormonal regulation) to insure the endometrium does not become hyperplastic.

Normal Menstrual Cycles

Mature, ovulatory women– 28-29 day average– 21-36 day range– 2-7 days duration– 20-80 cc of blood loss per month

Cycle Variation Women in their middle reproductive

years have the most predictable cycles More pronounced cycle to cycle

variability in the 5-7 years after menarche and 6-8 years before menopause

Cycle Variation (cont.) Adolescents

– Majority range 21-48 days– Usually anovulatory

– Mean time from menarche until half the cycles are ovulatory depends upon the age of menarche

– 12 yrs 1yrs till half cycles are ovulatory– 12-13 3yrs– >13 4.5 yrs

Cycle Variation (cont.) Perimenopause

– Cycles initially shorten– Ultimately (apparently) lengthen, as an

entire cycle will be skipped Average age of menopause is 51

– Cessation of menses for one year

Abnormal Uterine Bleeding

Menorrhagia Oligomenorrhea Metrorhhagia Polymenorhhea Menometrorhhagia Oligomenorrhea Contact bleeding

Terminology Amenorrhea—lack of menstrual bleeding

– Primary—no menses by age 16– Secondary—absence of 3 or more expected

menstrual cycles

Break-through bleeding (BTB) unexpected bleeding usually occurring while a woman is on exogenous hormonal medication (eg OCPs, patch, or ring)

Terminology (cont.) Menorrhagia—heavy menstrual bleeding.

Prolonged or excessive menstrual blood loss with regular cycles

Metrorrhagia—irregular, frequent bleeding Menometrorrhagia—irregular menses with

prolonged or excessive blood loss Midcycle bleeding—light menstrual

bleeding occurring in ovulatory women at the midcycle estradiol trough

Terminology (cont.) Oligomenorrhea-- menstrual

bleeding/menses occurring less frequently than 36 days apart

Polymenorrhea—frequent menstrual bleeding/menses occurring more frequently than 21 days apart

Contact bleeding/post-coital bleeding Dysmenorrhea- painful menstrual bleeding

Impact on Health 75% of women experience physical changes

associated with menses PMS (Premenstrual syndrome) PMDD (Premenstrual dysphoric disorder) Direct and indirect health care costs

– Visits to ED, clinic, or office– Time lost from work

PMS

Psychoneuroendocrine d/o with biological, social and psychological impacts

Up to 75% of women experience some level of recurrent sx

Up to 5% may experience severe sx and distress

Common PMS Symptoms

Headache Breast pain Bloating Irritability Fatigue Crying

Abd pain Clumsiness Sleep alteration Labile mood Social withdrawal Libido change Appetite change

Requisite Symptoms for PMDD Diagnosis

Depressed mood Anxiety/tension Mood swings Irritability Decreased interest Concentration

difficulties Fatigue

Appetite changes/food cravings

Insomnia/hypersomnia Feeling out of control Physical symptoms 5/11 symptoms

needed for diagnosis and

Sx disrupt daily functioning

PMS/PMDD Tx Limit caffeine, tobacco, alcohol and

sodium Frequent high-complex carb meals CBT, stress management, aerobic

exercise

Dysmenorrhea Painful menstruation- when pain

prevents normal activity and requires medication

Pain starts when bleeding starts Prostaglandin activity Emotional/psychological factors

Dysmenorrhea tx NSAIDs, starting a day before period

– Ibuprofen, naproxen Anti-prostaglandins much less

effective after pain is established Continuous heat to abd OCPs for 6-12 months have lasting

benefit

Ddx of Abnormal Uterine Bleeding

Blood Dyscrasias Anatomic causes of bleeding,

including pregnancy Anovulation Malignancy Non-uterine causes of bleeding

AUB work-up Hx PE with cytology Pelvic ultrasound Endometrial biopsy Hysteroscopy D & C

Leiomyomas (Fibroids) Benign neoplasms arising from uterine wall

smooth muscle cells 20-25% of reproductive age women Can be small to quite large, single or

multiple. Surrounded by pseudocapsule. Often asx, but can cause metrorrhagia,

menorrhagia, dysmenorrhea and infertility Cause unknown, but hormone responsive

Fibroid Tx Depends on sx, age, parity,

reproductive plans, general health, and size/location of leiomyomas

GnRH agonists- to shrink fibroid OCPs control bleeding but do not treat

the fibroid Progestin-releasing IUD for multiple

small leiomyomata

Fibroid Tx - Surgical Myomectomy- preserves fertility, high risk

for fibroid recurrence Hysterectomy- eliminates sx and chance of

recurrence. Also eliminates uterus. Uterine fibroid embolization (UFE)

– Embolic occlusion of uterine arteries– As effective as above, few recurrences, few

major complications

Anovulation Patient History—very important to

diagnosis– Ovulatory cycles—consistent number of

days from beginning of one cycle to the next, breast tenderness, and dysmenorrhea usually present

– Anovulatory cycles—variation in number of days per cycle, no breast tenderness, and dysmenorrhea is not consistent from one cycle to the next

DUB “Dysfunctional uterine bleeding” Abnormal uterine bleeding with

pathologic causes ruled out So..you’ve done all that stuff, and it’s

all okay Usually tx with hormones (ie OCPs) to

control bleeding

Non-uterine causes Genital neoplasms of the vulva or vagina

– To avoid missing vaginal lesions, stainless steel speculum blades should be rotated on removal to fully evaluate the vaginal mucosa

– Better: use plastic speculum with good light source

Genital trauma/foreign objects Rectal bleeding or urinary tract source

Evaluation History

– Menstrual pattern (duration, changes in quality, color of menses)

– Dysmenorrhea, mittleschmerz, breast changes

– Post-coital spotting– Dietary practices, change in weight,

exercise, stress– Evidence of systemic disease

Evaluation (cont.) Physical Exam

– Vital signs, height, weight, body phenotype, BMI– Skin, hair (acne, hirsutism pattern)

– Fat distribution, striae

– Thyroid

– Breast exam to check for galactorrhea– Complete pelvic exam– Tanner stage for teens

Evaluation--testing All patients:

– Pregnancy test– CBC with platelets– Recent Pap

Over 35 yrs:– Endometrial sample

Documented drop in hgb <10– PT, PTT

– Bleeding time

As indicated:– TSH– Prolactin– Testosterone– LH/FSH– 17-OH progesterone– Overnight

dexamethasone suppression test or 24 hr urinary free cortisol

– Hysteroscopy or ultrasound

Acute Bleeding: Control Oral progestins:

– Micronized Progesterone 200 mg (Prometrium) or Medroxyprogesterone 10 mg (Provera) or Norethindrone 5 mg (Aygestin)

– 1 po q4 hrs or until bleeding stops, then– 1 qid x 4 days– 1 tid x 3 days– 1 bid x 2 weeks, then – Cycle monthly with progestin or low dose oral

contraceptive

AUB Long Term Control Cycle with low dose OCP, patch, or vaginal

ring Cycle with a progestin, eg Prometrium Use of progestin-containing IUD (Mirena) Choice depends upon:

– Contraceptive need– Smoking status– Medical history– Patient preference

Endometriosis Abnormal growth of endometrial tissue

in locations other than the uterine lining

3-10% of women of reproductive age 30% of infertile women

E

Tx Analgesics (ibu) Hormones

– OCPs or progestins

– Danazol- prevents gonadotropin release, inhibits midcyle LH and GSH. Androgenic side fx

– GnRH agonists (Lupron)- with continuous admin, suppresses gonadotropin secretion

Assisted reproduction when desired

Amenorrhea Absence of menses Primary amenorrhea- no menses by age 16

with otherwise nl development Secondary amenorrhea- absence of

menses for 3 or more cycles or 6 months in a previously menstruating female– MC cause??– 3% in genl population– 100% under extreme stress

Examples?

Tx Desiring pregnancy?

– Ovulation induction Not desiring pregnancy?

– If hypoestrogenic, combo tx with estrogen and progesterone to maintain bone density and prevent genital atrophy

– Normal progestin challenge: needs occasional progestin to prevent endometrial hyperplasia and cancer

– OCPs work well for either, and can decrease hirsutism

– Calcium, too!

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