Reproductive System Module

Session 3 Lecture 2

Menstrual Dysfunction

Dr.Nassrin Malik Aubead

Aim of the lecture

This lecture will be introduced to the

main menstrual problems, presented

in the context of the ways in which the

hypothalamic pituitary ovarian axis

may fail

Objectives By the end of the presentation one should be able to:

1-Define the terms that are used to describe common menstrual abnormalities

2-Describe the effect upon the menstrual cycle of

-Changes in the hypothalamic control of GnRH secretion

- Changes in anterior pituitary function

- Changes in ovarian function

- Changes in uterine function

3-Discriminate between primary and secondary amenorrhoea

4-Identify common causes of menorrhagia, and irregular menstrual cycle

5- Identify common causes of painful periods

The Menstrual cycle : is a repetitive expression of the

interaction of the hypothalamic - pituitary - ovarian system

with associated structural and functional changes in the

target tissues of the reproductive tract (uterus, oviduct,

endometrium and vagina ) as an essential part of making

sexual reproduction possible

(i.e Production of eggs& Preparation of the uterus for pregnancy)

Characteristics of the normal menstrual cycle:

• Average length 28 days ( 21-35 days).

• Average duration 4 days (1-7 days).

• Amount 35 ml (< 80 ml)

Terms that are used to describe common menstrual abnormalities

• Menorrhagia: excessive (>80 ml) & /or prolonged bleeding at regular

intervals.(excessive flow and duration)

• Metrorrhagia: irregular menstrual bleeding(particularly between the

expected menstrual periods).

•Menometrorrhagia: excessive, prolonged & irregular bleeding.

• Intermenstrual bleeding: bleeding between normal menstrual periods.

•Postmenopausal bleeding: bleeding that occurs > 1 year after menopause, or at

irregular intervals while on HRT(other than the expected cyclic bleeding that occurs in

women taking cyclic postmenopausal hormone therapy).

• Dysmenorrhoea : Painful menstruation

•Dysfunctional Uterine Bleeding(DUB): Abnormal bleeding, no obvious organic cause.

Any abnormal bleeding Local organic

Systemic cause

DUB

• Polymenorrhoea: frequent menses occurring at < 21 days

interval.(Polymenorrhoea is a term for menstrual cycle abnormality in which

a woman gets her period very frequently every 20 day or even less often.

Mean her m.c is shorter than than 21 days long, so instead to of having an

average of 12 period per year, she could have as many as 17 or more.

• Oligomenorrhoea : is defined as irregular periods at intervals of more

than 35 days, with only 4–9 periods a year.

•Amenorrhoea: absence of menstruation.

Primary Amenorrhoea is defined as the absence of menstruation at 16 years age .

Secondary Amenorrhoea is defined as the absence of menstruation for more than 6 months in the

absence of pregnancy in a woman of fertile age.

•Cryptomenorrhoea: menstruation occurs but not visible due to obstruction in outflow

tract

•Hypomenorrhea: hypomenorrhoea, also known as short or scanty periods, is extremely light menstrual

blood flow. It is the opposite of hypermenorrhea which is more properly called menorrhagia.

•Anovulatory Cycles: No ovulation/ Oligo/Amenorrhoea +/- Menorrhagia

•Ovulatory Cycles: usually regular menstrual cycles +/- Menorrhagia

+ dysmenorrhea/mastalgia (sore breasts)

Amenorrhoea: define as absence of menstruation.

Amenorrhoea may be primary or secondary

• Primary amenorrhoea :is defined as the failure of initiation of menses by age

16 regardless of the presence of normal growth and development of secondary

sexual characteristics

• Secondary amenorrhoea :is absence of menstruation for more than 6 months

in a normal female of reproductive age that is not due to pregnancy, lactation or

the menopause.

The cause of amenorrhoea

The causes may be hypothalamic, pituitary, ovarian , uterine (endometrial ) and outflow tract

obstruction (vagina, cervix)

I-Hypothalamic disorders

Hypothalamic disorders will give rise to hypogonadotrophic hypogonadism, with the following causes:

• Constitutional delay: exclude other causes.

•Excessive exercise, stress, anorexia or bulimia, chronic diseases: led to weight loss ( Fall below

critical weight of 47kg).

• Hypothalamic lesions (craniopharyngioma, glioma), which can compress hypothalamic tissue or block

dopamine.

• Head injuries.

• Kallman’s syndrome (X-linked recessive condition resulting in deficiency in GnRH ,causing unovulation

and amenorrhoea, underdeveloped genitalia).

• Systemic disorders including sarcoidosis, tuberculosis resulting in an infiltrative process in the

hypothalamo-hypophyseal region.

• Drugs: Drugs affecting HPG axis (progestogens, HRT) or dopamine antagonists.

II-Pituitary disorders Pituitary disorders will also give rise to hypogonadotrophic hypogonadism, with the

following causes:

• Adenomas, of which prolactinoma lead to hyperprolactinaemia is most common.

• Pituitary necrosis (Hypopituitarism) e.g. Sheehan’s syndrome, due to prolonged

hypotension following major obstetric hemorrhage.

• Iatrogenic damage (surgery or radiotherapy).

• Haemochromatosis – ‘Iron overload’

• Congenital failure of pituitary development.

Amenorrhoea may also be caused by hypo/hyperthyroidism or adrenal disease.

The mechanism of Hypothalamic/Pituitary Amenorrhoea (Hypogonadotrophic hypogonadisim amenorrhoea)

Inadequate levels of FSH lead to inadequately stimulated

ovaries, which then fail to produce enough oestrogen to

stimulate the endometrium of the uterus, giving amenorrhoea.

In general, women with hypogonadotropic amenorrhoea are potentially

fertile.

III- Gonadal/End-Organ Amenorrhoea

In Ovarian Amenorrhoea the ovary does not respond to pituitary stimulation,

giving low oestrogen levels. The lack of –‘ve feedback from oestrogen leads to

elevate FSH levels in the menopausal range

(Hypergonadotrophic hypogonadism amenorrhoea).

Primary Gonadal/End-organ

1-Gonadal dysgenesis – e.g. Turner Syndrome (45, Xo)

2-Androgen Insensitivity Syndrome

3-Receptors abnormalities for FSH and LH.

Secondary Gonadal/End-organ

1-Premature menopause :premature ovarian insufficiency formerly known as

premature ovarian failure (POF) is defined as cessation of periods before 40 years

of age

2-Polycystic Ovarian Syndrome

PCOS

IV-Uterine cause:- A- Absent uterus :Mullerian agenesis i.e. absent vagina & uterus

(Rokitansky syndrome),15% of primary amenorrhoea.

B-Endometrial disorders: Lead to secondary amenorrhoe.

-Asherman syndrome: scarring and adhesion of the endometrium .

-Tuberculosis of the endometrium: lead to endometrial atrophy.

Asherman syndrome

V- Outflow Tract Amenorrhoea

Primary outflow tract obstruction

* Mullerian agenesis i.e. absent vagina

•Vaginal atresia or complete transverse vaginal septum,

•imperforate hymen leading to a haematocolpos.

Secondary outflow tract obstruction

*Cervical stenosis as in case of conization of the cervix

some time lead to cervical incompetence in this case it not cause abstraction and

amenorrhoea ,instead it resulting in recurrent abortions

* severe and complete vaginal adhesion following vaginal surgery

In Amenorrhoea of endometrial cause or outflow tract origin, the Hypothalamic

-Pituitary-Ovarian Axis is functional, therefore FSH level is normal

. Causes of primary amenorrhoea

Hypothalamic causes (hypogonadotrophic hypogonadism)

Constitutional delay Congenital :Isolated GnRH deficiency -Olfacto‐genital syndrome-(Kallman’s syndrome ) Acquired : Weight loss/anorexia Excessive exercise Chronic illness Tumours Psychological distress

Pituitary causes Hyperprolactinaemia

Ovarian causes Gonadal agenesis :XX agenesis XY agenesis Gonadal dysgenesis:Turner syndrome XY enzymatic failure(5α‐Reductase deficiency) Ovarian failure Galactosaemia Polycystic ovary syndrome

Uterine and outflow causes Imperforate hymen Complete transverse vaginal septum Mullerian agenesis i.e. absent vagina & uterus (Rokitansky syndrome), Absent vagina and functioning uterus Absent vagina and non‐functioning uterus

Other causes Congenital adrenal hyperplasia Androgen‐secreting tumour

Evaluation of primary amenorrhoea

Confirm normal prolactin and thyroid hormones

. Causes of secondary amenorrhoea

Hypothalamic causes (hypogonadotrophic hypogonadism)

Weight loss Exercise Chronic illness Psychological distress Idiopathic

Pituitary causes Hyperprolactinaemia Hypopituitarism (Sheehan’s syndrome)

Causes of hypothalamic/pituitarydamage (hypogonadism)

Tumours (craniopharyngiomas, gliomas,germinomas, dermoid cysts) Cranial irradiation Head injuries Sarcoidosis Tuberculosis Chronic debilitating illness

Ovarian causes Polycystic ovary syndrome Premature ovarian insufficiency (genetic, autoimmune, infective, radiotherapy/chemotherapy)

Uterine causes Asherman’s syndrome Cervical stenosis

Systemic causes Weight loss Endocrine disorders :thyroid disease,Cushing’s syndrome

Evaluation of Secondary Amenorrhoea

History

- Menstrual history

Ever had one before? What was cycle like before?

- Contraception

- Pregnancy

- Surgery

- Medication

- Weight change

- Chronic diseases, stress, diet

- Family history

* Age at menopause, thyroid dysfunction, diabetes, cancer

Physical examination

* BMI – Weight change

* Hair distribution – PCOS leads to hirsutism

*Thyroid

* Visual fields / Breast discharge – Hyperprolactinaemia

*Abdomen-masses? Tenderness?

Management of Amenorrhea

Any amenorrhea

Do pregnancy test

The management of amenorrhea varies widely depending on the cause. If due to

insufficiency in a hormone, the amenorrhea may be treated with hormone

replacement. If due to lifestyle (e.g. exercise, weight loss) can be treated by

modifying these factors. Medical &/or surgical treatment

might be required according to the cause

Abnormal uterine bleeding

1-Dysfunctional Uterine Bleeding (DUB)

-Also called “ bleeding of endometrial origin

-Is abnormal bleeding in the absence of organic disease of the genital tract

-It is a dx of exclusion.

-It is classified into ovulatory and anovulatory.

A-Anovulatory DUB ( >90%):

-There is no corpus luteum formation & Progesterone production. As a

result E2 is produced continuously, causing overgrowth of the uterine

endometrium &subsequent bleeding.

-Commonly occurs at extremes of reproductive age and irregullar.

*In perimenarchal adolescents, it is due to immaturity of HPG axis(unable

to respond to E2 with an LH surge).

* In perimenopausal women it is due to declining ovarian function.

-Usually irregular.

- More common in obese women ( peripheral conversion of androgen to

esteron).

B-Ovulatory DUB:

- 19% of DUB is happen when ovulation is occurring, but there may be

altered life span of corpus luteum or abnormal progesterone production.

This causes irregular shedding of the uterine lining and erratic bleeding.

-Disordered endometrial prostaglandin production also has been

implicated, as have abnormalities of endometrial vascular development

-age usually 35-45 yr.

-Regular, heavy & often painful menstrual periods.

The diagnosis of DUB is one of exclusion, as other potential causes

for the bleeding must be ruled out

-Beta HCG(Exclude pregnancy)

TSH (thyroid)

-Coagulation workup

-Cervical Smear if appropriate – Exclude cancer ( Cervical )

-Sample endometrium dilatation and curettage( D & C )

2-Menorrhagia

Menorrhagia is regular heavy vaginal bleeding . It is usually

secondary to distortion of the uterine cavity, leaving the uterus

unable to contract down on open venous sinuses in the zona basalis.

It may be due to dysfunctional uterine bleeding (DUB) & usually ovulatory.

Other causes include organic, endocrine, or haemostatic.

*6-Pellvic inflammatory disease ( PID )

* 7- Thyriod disease

*8- Drug therapy ( warfarin )

*9- Intrauterine contraceptive device

*10- Endometrial /Cervical carcinoma

Causes of Menorrhagia

*1-DUB

* 2-Fibriod

*3-Adenomyosis

*4-Endometrial polyp

*5-Coagulation disorder

(von Willebrands disease )

Dysmenorrhea (painful periods)

- cramping pain in the lower abdomen .It is experienced by 45–95 % of

women of reproductive age.

-Primary Dysmenorrhea: occurring just before or during menstruation, in

the absence of other diseases

- It improves after childbirth, & it also appears to decline with increasing age

Secondary Dysmenorrhea :secondary dysmenorrhea results from

reproductive system disorders Like :

• endometriosis and adenomyosis;

• pelvic inflammatory disease;

• cervical stenosis and haematometra (rare).