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

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Presentation on theme: "Menstrual Cycle Disorders Karen Estrella H. Pediatric PGY-2 SBH Nov/2010."— Presentation transcript:

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: – Median age: 12.7 yrs – African-american earlier than Caucasian – 2-2.5yrs after breast development – Anovulatory cycles: 1 st 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

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 Classification: 1.With pubertal delay 2.With normal pubertal development 3.Genital abnormalities 4.Hyperandrogenic anovulation

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

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: 1.PCOS (polycystic ovarian syndrome) – Most common 2.Ovarian and adrenal tumor or adrenal enzyme deficiency 3.Obesity

15 EVALUATION

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

17 Secondary amenorrhea >100ng/ml 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 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. POSITIVE TEST: withdrawal bleeding 2-7 days after – +uterus – Insufficient estrogen stimulation

19 Dysfunctional Uterine Bleeding

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

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 1 st 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 1 st day of bleeding Prevent ovulation and decrease endometrial growth – Oral contraceptives 30-35mcg combined estrogen-progestin x4-6months Laparoscopy

26 SUMMARY

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