1. Menstrual Cycle Disorders
Karen Estrella H.
Pediatric PGY-2 SBH
Nov/2010

2. Objetives Introduction Normal physiology Definitions
Menstrual Cycle disorders
Amenorrhea
Dysfunctional Uterine Bleeding
Dysmenorrhea

3. Introduction Menarche: Duration: Median age: 12.7 yrs
African-american earlier than Caucasian
2-2.5yrs after breast development
Anovulatory cycles: 1st 1-2yrs of onset (55-82%)
For 5 yrs (10-20%)
Duration:
Between 21 and 35 days (mode: 28)
Lasting: 3-7days
Blood lost: 30-40ml

4. Physiology

5. Physiology

6. Definitions Amenorrhea:
Primary: absence of menarche by age 16 in the presence of normal pubertal development (Tanner 4-5)
Or: lack of menses by age 14 in absence of pubertal development
Secondary: absence of 3 consecutive menstrual cycles or 6 months of amenorrhea
Menorrhagia: normal intervals with excessive flow
Cycles more than 8days, > 80ml
Metrorrhagia: irregular intervals with excessive flow
Oligomenorrhea: menstruation ocurring more than every 35 days to 6 months

7. Menstrual Cycle Disorders

8. Amenorrhea

9. Amenorrhea Classification: With pubertal delay
With normal pubertal development
Genital abnormalities
Hyperandrogenic anovulation

10. Amenorrhea 1. With pubertal delay
Hypergonadotropic hypogonadism
OVARIAN FAILURE
Turner
XY gonadal dysgenesis
Autoinmmune oophoritis
Exposure to chemo or RT(alkylating)
17 alpha hydroxylase deficiency
Elevated FSH B A

11. Amenorrhea 1. With pubertal delay B. Hypogonatropic hypogonadism
PITUITARY:
Adenoma
Prolactinoma
Craniopharyngioma
Hemochromatosis
Hypothyroidism
Breast stimulation Sx
Phenothiazines, opiates
(-PRL inhibitor factor)
HYPOTHALAMIC:
Suppresion:
Stress
Malnourishment
Wt loss < 15% of ideal body wt
Strenous exercise
Body fat < 22%
If prior to menarche, each yr of training delays onset by 5 months
Prader-Willi
Kallman
Migration olfatory and GnRH neurons)
Low or normal FSH

12. Amenorrhea 2. with normal pubertal development
Pregnancy
Chronic diseases
Exc IBD, DM, hypothyroidism, anorexia
Use of hormonal contraceptive
Progestational effect
Uterine synechiae (Asherman sd)
Sheehan sd.

13. Amenorrhea 3. Genital tract abnormalities
Outflow tract-related:
Imperforate hymen
Transverse vaginal septum
Agenesis of the vagina, uterus:
Mullerian Agenesis: breasts, (+) pubic and axillary hair
Testicular feminization (x-linked defect androgen receptor): breast, (-) pubic axillary hair

14. Amenorrhea 4. Hyperandrogenic anovulation
Hirsutism, acne, rarely clitoromegaly
To be r/o:
PCOS (polycystic ovarian syndrome)
Most common
Ovarian and adrenal tumor or adrenal enzyme deficiency
Obesity

15. EVALUATION

16. Primary amenorrhea Presence of breasts Surgery Hormone replacement TSH
PRL
MRI brain
testosterone
Surgery
Enzymatic defect
Hormone replacement

17. Secondary amenorrhea DHEAS: > 700ng/ml Testosterone >90ug/ml
Abd-pelvic MRI
17OH progesterone
Asherman
Hirsutism: spirinolactone 50mg po TID

18. Evaluation: Secondary amenorrhea
Progesterone challenge test:
Oral medroxyprogesterone acetate for 5-10 mg QD for 5-10 days), or IM 200mg x1.
POSITIVE TEST: withdrawal bleeding 2-7 days after
+uterus
+estrogen stimulation: ovaries ok
Estrogen-progesterone challenge test:
Oral conjugated estrogen (1.25 mg) or 2 mg estradiol qd for days 1 through 21 with oral medroxyprogesterone acetate (10 mg) on days 17 through 21.
Insufficient estrogen stimulation

19. Dysfunctional Uterine Bleeding

20. Dysfunctional Uterine Bleeding
Prolonged # of days of bleeding or excessive bleeding
Most common: anovulation
the lack of progesterone secretion increases risk of endometrial hyperplasia
High estrogen levels
Bleeding is prolonged, irregular and sometimes profuse
Adolescents
Obese

21. DUB: Differential dx Pregnancy STD’s PID Foreign bodies
Cervical neoplasia
Coagulation defect: vWF

22. DUB: Treatment

23. DYSMENORRHEA

24. Dysmenorrhea (painful menses)
Primary:
Decrease of progesterone levels al end of luteal phase: lysosomal membranes are unstable::::release enzymes formation:
Prostaglandins
Keep increasing during luteal and menstrual phases
Uterine hypercontractibility
Tissue ischemia
Nerve hypersensitivity
(just before or 1st days of menses)
Secondary:
Associated with pelvic pathology:
Endometriosis
Miomas
PID
STD
Genital tract obstruction
(Later age, Menorrhagia, Dyspareunia, Pain with defecation, worsening with every cycle or mid-cycle, symptoms that persist after menses have finished)

25. Dysmenorrhea: Treatment
Inhibiting prostaglandin synthesis:
Ibuprofen: mg po q4-6hrs
Naproxen 500mg load then 250mg po q6-8hrs
Started on 1st day of bleeding
Prevent ovulation and decrease endometrial growth
Oral contraceptives
30-35mcg combined estrogen-progestin x4-6months
Laparoscopy

26. SUMMARY

27. References