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 Abnormal Uterine Bleeding (RCGP)

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PostSubject: Abnormal Uterine Bleeding (RCGP)   Thu May 03, 2012 1:12 am

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Abnormal Uterine Bleeding
 
   Abnormal uterine bleeding is a common problem encountered in general practice.



Classification of Abnormal Uterine Bleeding
     Abnormal Rhythm

  • Irregularity of the cycle
  • Inter menstrual bleeding (metorhagia)
  • Post coital bleeding
  • Postmenopausal bleeding

     Abnormal Amount

  • Increased amount = menorrhagia
  • Decreased amount = hypomenorrhoea

     Combination (Rhythm and Amount)

  • Irregular and heavy periods = metromenorrhagia
  • Irregular and light periods = oligomenorrhoea

     Key Facts and Checkpoints

  • Up to 20% of women in the reproductive age group complain of increased menstrual loss.
  • At least 4% of the consultants in general practice deal with abnormal uterine bleeding.
  • Up to 50% of the patients
    who present   with perceived menorrhagia ( or excessive blood loss)
    have a normal   blood loss when investigated.
  • The possibility of
    pregnancy and its   complications, such as ectopic pregnancy, abortion
    (threatened, complete   or incomplete), hydatidiform mole or
    chroriocarcinoma should be kept in   mind.
  • The mean blood loss in a menstrual cycle is 30 –40 ml.
  • A menstrual record is a useful way to calculate blood loss.
  • Blood loss is normally less than 80 ml.
  • Menorrhagia is a menstrual loss or more than 80 ml per menstruation.
  • Menorrhagia disposes women to iron efficiency anaemia.
  • Various drugs alter menstrual bleeding e.g. anticoagulants , cannabis, steroids.

     Defining what is Normal and what is Abnormal

     This feature is based on a  
meticulous history, an understanding of the physiology and   physiopathology of the menstrual cycle and a clear understanding of what
  is normal. Most of the girls reach menarche by the age of 13 ( range
 10- 16). Dysfunctional bleeding is common in the first 2 –3 years
after   menarche due to many anovulatory cycles resulting in irregular
periods   and probably dysmenorrhoea.

     Once ovulation and regular  
menstruation are established the cycle usually follows a predictable  
pattern and any deviation can be considered as abnormal uterine  
bleeding. It is abnormal if the cycle is less than 21 days, the duration
  of loss is more than 8 days or the volume of loss is such that  
menstrual pads of adequate absorbency cannot cope up with the flow or  
clots.
     Relationship of Bleeding to Age

     Dysfunctional uterine bleeding
 is more common at the extremes of the reproductive era. The incidence
of   malignant disease as a cause of bleeding increases with age, being
 greatest after the age of 45 , while endometrial cancer is predicted
to   be less than 1 in 100 000 in women under the age of 35.


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Menorrhagia
     Menorrhagia is cyclical  
bleeding at nornal intervals which is excessiue in amount and duration  
i.e. 5/28 or 8/28. Is essentially caused by hormonal dysfunction (  
e.g.anovulation), local pathology (e.g. fibroids) or medical disorder  
(blood dyscrasia). In Menorrhagia the menstrual cycle is unaltered but  
the duration and quantity of menstrual loss are increased. Menorrhagia
 is essentially a symptom and not in itself a disease. Heavy bleeding,
 associated with clots is the major symptom of menorrhagia.
Dysmenorrhoea   may accompany the bleeding and, if it does,
endometriosis or pelvic   inflammatory disease (PID) should be
suspected. With care 60 – 80%   accuracy can be achieved in clinical
assessment.

     Etiology:

     General Diseases Causing Menorrhagia

  • Blood dyccrasias i.e leukemia, coagulopathy , thrombocytopenic purpura, severe anaemia.
  • Thyroid dysfunction – hypo and hyper thyroidsim in initial stages.
  • One of the Commonest causes of menarrhagia in administration of Exogenous estrogen for Climactric symptoms.

     Local Causes

  • Uterine fibroids, fibroid polyps.
  • Chocolate cyst, ovarian feminizing tumours, PCOD, endometriosis, adenomyosis.
  • Salpingo – oophoritis , pelvic inflammatory disease, genital TB.
  • Immediate puerperal and post abortal periods.

     Iatrogenic Causes are

  •          Oestrogen and progesterone administration ( minipil)
  • The Intrauterine Contraceptive Device
  • 5 – 10 % of women using the device suffer from menorrhagia in the first few months.
  • Post sterilization it is reported in 15 % of cases but the etiology is not clear.

     Hormonal: Dysfunction Uterine Bleeding

     Clinical Approach for Menorrhagia

     History

     A detailed history is the key  
initial step in the management. A patient’s perception of abnormal  
bleeding may be quite misleading and education about normality is all  
that is necessary in her management. 30% of Premenopausal women perceive
  their menses to be excessive, reports show that only 10% of these
women   have clinical menorrhagia. A history should include details of
number   of tampons or pads used and the degree of saturation. A
menstrual   calendar (over 3 months) can be a very useful guide. A
history of   smoking and other psychological factors should be checked.
For unknown   reasons cigarette smokers are five times more likely to
have abnormal   menstrual cycles.

     Questions need to be directed to rule out

  • Pregnancy or Pregnancy Complication, e.g. Ectopic Pregnancy, abortion
  • Trauma of the Genital Tract
  • Medical disorders e.g. bleeding disorders
  • Endocrine disorders
  • Cancer of genital tract
  • Complications of the pill

     Physical Examination

     A general physical examination
 should aim at ruling out anaemia, evidence of bleeding disorders and
any   other stigmata of relevant medical or endocrine diseases.

     Specific Examination Includes:

  • Speculum examination - ulcer (cervical cancer)or polyps
  • Pap smear
  • Bimanual pelvic examination - uterine or adnexal tenderness, size and regularity of the uteru

     Vaginal examination is avoided
 in selected patients, such as a young virgin girl, as the procedure is
  unhelpful and unnecessarily traumatic.

     Investigations especially  
vaginal ultrasound scans should be selected very carefully and only when
  really indicated. Abnormal pelvic examination findings , persistent  
symptoms , older patients and other suspicious of disease indicate  
further investigation to confirm symptoms of menorrhagia and exclude  
pelvic or systemic pathology.

     Consider foremost:

  •          Full blood count (to exclude anaemia and thrombocytopenia)
  • Iron studies: serum ferritin
  • Endometrial biofosy or D & C
  • Hysteroscopy and endometrial sampling   (use directed endometrial biopsy with an


    instrument such as Pipelle or   Gynnoscann or curettage under general
    anasesthetic)


     Special investigations (only if indicated)

  •          Pregnancy testing
  • Laparoscopy where endometriosis .PID, or other pelvic pathology is suspected
  • Serum biochemical screen
  • Coagulation screen
  • Thyroid function tests
  • Tests for SLE: anti nuclear antibodies

     Treatment of Menorrhagia

     Treatment depends on several factors:
     

  1. The age of the patient, her fertility and her desire for children. Under forty, treatment is essentially conservative.
  2. The degree of anaemia.
  3. The response to curettage, which is   performed primarily as an aid to diagnosis, may be



    therapeutically   beneficial. There is no scientific explanation why
    curettage should   benefit dysfunctional bleeding. Curettage should therefore precede   hysterectomy in almost every instance.


     Conservative Treatment:   If the bleeding is not very heavy and the patient’s haemoglobin is  
normal, observation and maintenance ofmenstrual chart for a few months  
is in order. Sponstaneous cure is possible and can be awaited. In a  
patient suffering from severe dysfunctional bleeding, some degree of  
anaemia is to be expected. Oral iron should be given and the response to
  it checked by serial blood counts. Systemic iron should be given to  
those patients where oral iron is not tolerated. Rest, sedative and  
reassurance must not be neglected. Blood transfusion is needed in severe
  anaemia.

     Hormone Therapy
     

  1. Oestrogen.
    The aim of treatment is to raise the blood oestrogen level  


    to the super-threshold for bleeding and to achieve this a large initial
      dosage is necessary. This means administration of ethinyl oestradiol,
      0.25 mg t.d.s . It is, therefore, necessary to continue an artificial
      cycle at a fairly high level of blood oestrogen by maintaining
    ethinyl   oestradial dose of 0.25 mg daily for 21 days. During the last
    10 days of   this artificial cycle, 10 mg of oral progestational steroid
    is given.   The 3 weeks cyclical treatment is continued for the next
    three to six   months, after which the patient is kept under
    observation. Today,   oestrogen alone is not advocated because of the
    cardiovascular side   effects of high dosage and the risk of developing
    carcinoma of breast   and endometrium.
               
             

  2. The newer orally active progestational   steroids, such as nor-ethynodrel, nor-ethisterone or lynestrenol are   used as an alternative and these are safer than


    oestrogen. A high   initial dose of 10 to 30 mg a day should arrest bleeding in 24-28 hours,   after which 5 mg a day for 20 days is given.
    Withdrawal bleeding occurs   two to five days after cessation of treatment and a normal loss is to   be expected. A second course of 5 mg
    daily is given from day 5 for 20   days, after which withdrawal
    menstruation should occur. This treatment   can be continued for three
    to six months and should be stopped to   observe the patient. Duphaston
    does not suppress ovulation, has no   adverse effect on low LDL and is
    useful in young women desirous of   pregnancy. Medroxyprogesterone
    acetate (MDPA) 10 mg tab is also free of   adverse effect on
    lipoproteins.
               
               Progestogen impregnated IUDs (progestasert), also reduce  
    blood loss in 97% cases and are as effective as endometrial ablation  
    done hysteroscopically. Another advantage is the IUD can be left in for a
      year, offering one time treatment.
               
               Instead of 3 week cyclical therapy, luteal phase  
    administration of progestogen minimizes the duration of therapy, though
     it may not be as effective.
               
             

  3. Danazol is androgenic and is not   recommended as a drug of choice in cases of menorrhagia, more



    so in   young women. Short term tratment (6 or less)in severe
    menorrahagia,   given in a doseof 100 – 200 mg daily.
             

  4. Combined oral contraceptive pills are   useful in menorrhagia if a woman does not



    desire a pregnancy. It is more   effective than oestrogen or progestogen
    alone. It reduces blood loss by   50% and eliminates dysmenorrhoea. The
    first line therapy e.g. 50 m g   oestrogen   1 mg norethisterone:
    norinyl.
               
             

  5. Clomiphene is advocated if pregnancy is desired, and if cycles are anovulatory.
  6. Ethamsylate reduces the capillary   fragility; 500 mg 4 times a day started from 5 days prior to



    the   anticipated start of the period to 10 days after, reduces
    menorrhagia by   50%. No major side effects have be reported.


     NSAID:
Mefenamic acid 500 mg t.i.d. taken during meals and given during  
menstruation for 5-6 days controls menorrhatgia in 70% cases of  
ovulatory cycles or naproxen 500 mg T.I.D. or Ibubrufen 800 mg statum  
then 400 mg 8 hourly.

     Antifibrinolytic Agents:
Tranexamic acid 1-2 g 4 times a day for 6-7 days during menstruation.  
Nausea, vomiting, diarrhoea, headache, visual disturbances and  
intracranial thrombosis have been reported.

     GnRH: Administration by nasal sprays (synarel) or monthly implants (zoladex) to induce medical “menopause” 3-6 months.

     Typical treatment options for acute and chronic heavy bleeding

     Acute Heavy Bleeding

  • Curettage/hysteroscopy
  • Oestrogens (Premarin 25 mg) or oral high-dose progestogens
             e.g. norethisterone 5-10 mg 2 hourly until bleeding stops then 5 mg bd otds for 14 days

     Chronic Bleeding

  • For anovulatory women

    • Cyclical oral progestogens for 14 days
    • Tranexamic acid

         </li>
  • For ovulatory women

    • Cyclical prostaglandin inhibitor e.g. mefenamic acid
    • Oral contraceptive
    • Antifibrinolytic agent, e.g. tranexamic acid 1 g (o) qid, days 1-4
    • Progesterone-releasing IUDs

          </li>



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Dysfunctional Uterine Bleeding
     Dysfunctional uterine bleeding
 (DUB), which is a diagnosis of exclusion, is defined as excessive  
bleeding, whether heavy, prolonged or frequent of uterine origin, which
 is not associated with recognizable pelvic disease, complications of  
pregnancy or systemic diseases. If on bi manual examination the uterus
 and appendages are found to be normal the term dysfunction uterine  
bleeding is used.

     The etiology is purely hormonal
  and  the hypertrophy and hyperplasia of the endometrium are induced
by   high titres of oestrogen in circulating blood.

                                                                                                                                                                                                                                                                                       






Classification of Dysfunctional Uterine Bleeding






Anovulatory






Ovulatory
Thereshold bleeding of              puberty menorrhagia Irregular ripening
Metropathia haemorrhagicaIrregular shredding
Premenopausal dysfunction               uterine bleedingIUCD insertion
Following               sterilization               operation
     Puberty Menorrahagia:

     Is a threshold bleeding of  
adolescence caused by excessive or un opposed oestrogens and absence of
 progesterone in the anovulatory cycle.

     Premenopausal Menorrhagia:

     Is seen in women in anovulatory
  cycle. It is essential to rule out endometrial carcinoma by
dilatation   curettage, uterine aspiration or hysteroscopic directed
biopsy.

     Features


  • It is a working clinical diagnosis based   on the initial detailed history, normal physical



    examination and normal   initial investigation.
             

  • Very common: 10-20% incidence of women at some stage.
  • Peak incidence of ovulatory DUB in late   thirties and forties (35-45 years).Anovulatory



    DU B has two peaks: 12-16   years and 45-55 years.
             

  • Anovulatory DUB has two peaks: 12-16 years and 45-55 years.
  • The majority complains of menorrhagia.
  • Up to 40% with the initial diagnosis of   DUB will will have other pathology (e.g.



    fibroids, endometrial polyps)   if detailed pelvic endoscopic
    investigations are undertaken.


     Symptoms

  • Heavy bleeding: saturated pads, frequent changing, ‘accidents’, ‘flooding’, and ‘clots’.
  • Prolonged bleeding – menstruation > 8 days Or heavy bleeding > 4days.
  • Heavy bleeding- periods occur more than once every 21 days.



               
             
  • Pelvic pain and tenderness are not usually prominent features.

     Management Principles

  • Establish diagnosis by confirming symptoms and exclude other pathology.
  • If no evidence of iron



    deficiency or   anaemia, and significant pathology has been excluded,
    prospective   assessment of the menstrual pattern is indicated using a
    menstrual   calendar.
               
             

  • Conservative management is usually employed if the uterus is of normal size and there is no evidence of anaemia.
  • Drug therapy is indicated if symptoms are   persistently troublesome and surgery is



    contra-indicated or not desired   by the patient.
               
             

  • Provide reassurance about the absence of   pathology, especially cancer, and give counseling to



    maximize compliance   with treatment.
               
             

  • Consider surgical management if fertility   is no longer important and symptoms cannot be



    controlled by at least   3-4 months of hormone therapy.
               General rule: < 35 years – medical treatment
               
             

  • 35 years – hysteroscopy and direct endometrial sample (diagnostic-sometimes Therapeutic)

     Treatment

     Treatment is governed by factors such as age, amount of bleeding, associated conditions.

     I. General

     When bleeding is heavy advise  
bed rest, sedatives if necessary, advocate normal activity between  
episodes of bleeding, treat anemia if present.

     II. Medical Management
     

  1. Non-hormonal methods





    1. Prostaglanding synthetase inhibitors:
      Mefanamic acid   250 – 500 mg tid is effective in reducing menstrual
      loss by 25% other   agents that can be used are Diclofenac Ibuprofen and
      Naproxen.
    2. Antifibrinolytic agents EACA 3gms 4
      times daily or   Tranexamic acid lgm 2-4 times a day. These agents can
      reduce menstrual   loss by 50%. These may be tried when hormonal
      treatment is   contraindicated.

             
           </li>
  2. Hormones



               
               Play a very important role in women of reproductive age and rarely used after the age of 40.
               
               The drugs used are estrogens, progestogens and estrogen – progestogen  combination.

    1. Estrogens: indicated when bleeding is
      very heavy and   unresponsive to progestogens and in anovulatory
      bleeding conjugated   equine estrogen (CEE) 12.5 mg IV to stop bleeding
      and repeat after 12hrs   if necessary. Subsequently use OC pills or
      progestogens.
    2. Progestogens: Oval synthetic
      progestogens or   injectable progestogens can be used in avovulatory DUB
      in girls and   young women. “This is known as medical curettage”
      hyperplastic   endometrium converted into secretary endometrium to
      precipitate shedding   when treatment stopped.
                     
                     10-30mg of Norethistorone acetate daily is given in  
      heavy bleeding till it stops then treatment is stopped, withdrawl  
      bleeding starts in 2-3 days and stops on its own accord.
                     
                     If prolonged heavy bleeding occurs then repeat the cycle.
                     
                     To avoid relapses usually dehydro progesterone a  
      medroxyprogesterone is given from 16-25 days of cycle, this is continued
        for 3-6 cycles.
    3. Oestrogen – Progestogens Combination:
                     
                     Combined oral contraceptive pills can be used in  
      ovulatory DUB. This treatment may not control bleeding in 20% of cases,
       in these cases its advisable to use pill with higher estrogen content.
    4. 1UCD: Intrauterine progesterone and
      Levonorgestrel   1UCD have also been found to be effective. This has the
      advantage of   avoiding daily intake of tablets and side effects are
      low.
    5. Androgens: These compounds are useful
      in all types of   DUB but avoided due to unpleasant side effects like
      virilization. Mostly   used in women more than 40 years age drugs used
      are methyl testosterone   5-10mg daily for 2 months.
                     
                     Mixed preparations of Androgen and estrogen and androgen and progesterone are used for hemostatic purpose.
                     
                     Another useful drug is Danazole 200-400mg for 12 weeks, effective in reducing blood loss by 50%.
    6. GnRH Analogues:
                     
                     Used in anovulatory DUB and endometrial hyperplasia.

             
           </li>

     III. Surgical Treatment:

     The determining factor for  
surgical modality of treatment in DUB is age, last resort, in young  
patients and can be considered in women above 40 years of age.
     

  1. D & C: D&C is primarily done for diagnostic purpose and same times may have Curative benefit in some cases.



               
             
  2. Endometrial Ablation:

    Endometrial layer of uterus is ablated by using  



    electrocautery.The procedure is relatively simple, used mainly in cases
     where patient desires to retain uterus and has no desire for
    pregnancy,   can be used in cases where there are medical
    contraindications for   surgery.
               

  3. Hysterectomy:



               
               This surgical remedy is used in patients above 40 years and
     in cases where simple treatment has failed to give respite. Can be
    done   vaginally or by abdominal route.


     IV. Radiotherapy:

     In rare cases where surgery is
 contraindicated and medical measures are  ineffective DUB can be  
controlled by external irradiation.

     Cycle Irregularity

     For practical purposes, patients with irregular menstrual cycles can be divided into those under 35 and those over 35 years.

     Patients under 35:

  •      The cause is usually hormonal, rarely organic, but keep malignancy in mind


  • Management options
  • Explanation and reassurance (if slight irregularity).



    1. COC pill for better cycle control – any pill can be used.
    2. Progestogen-only pill (especially anovulatory cycles) norethisterone (Primolut N) 5-15 mg/day from day 5 –25 of cycle.

             
          </li>

     Patients over 35 should be  
referred for investigation for organic pathology, usually  endometrial  
sampling and / or hysteroscopy. If normal, the above regimens can be  
instituted.

     Intermenstrual Bleeding and Postocaital Bleeding

     These bleeding problems are due
  to factors such as cervical ecotropion (often termed cervical  
‘Erosion’), cervical polyps, the presence of an IUCD and the oral  
contraceptive pill. Cervical cancer and intrauterine cancer must be  
ruled out. Hence there is importance of a Pap smear in all age groups  
and endometrial sampling, especially in the over 35 age group. Refer  
women with bleeding problem associated with abnormal smear. Those with a
  friable ectropion that is causing persistent symptoms should also be
 referred. Thus inter menstrual bleeding should always be investigated.

     Cervical ectropion, which is  
commonly found in women on the pill and post partum, can be left  
untreated unless intolerable discharge or moderate post coital bleeding
 is present. An IUCD should be removed if causing significant symptoms
 and the causative pill should be changed to one with a higher
oestrogen   dose (e.g. from 30 ug oestrogen to 50 ug oestrogen).

     Amenorrhea

     Amenorrhea is the absence of menstrual bleeding. It is a normal feature in prepubertal, pregnant, and postmenopausal females.

     False Amenorrhea
     It is a condition where there  
is absence of menstrual flow due to outflow obstruction at the level of
  the cervix, vagina or vulva. It presents as amenorrhea although  
menstruation is taking place. This is also known as cryptomenorrhea.

     True Amenorrhea

     It is the condition in which menstrual function is suppressed due to physiological or pathological causes.

     

  • Physiological

    • Before puberty
    • Adolescence
    • Pregnancy
    • Lactation
    • Menopause

           </li>
  • Pathological

    • Primary
    • Secondary

           </li>

     Physiological Amenorrhea

     Before puberty

     Amenorrhea is normal during  
childhood. Menstruation is usually established by the age of 16 years  
but may not appear until the age of 18 years without any abnormality.

     Adolescence

     Initial menstrual cycles are  
often anovulatory and therefore irregular. Periods of amenorrhea lasting
  for 2-12 months after menarche for 1-2 years are regarded as normal.

     Pregnancy

     It is the most common cause of
 secondary amenorrhea. The amenorrhea is due to continuous production
of   estrogen and progesterone by the chorion.

     Lactation

     Menstruation is suppressed for a varying period of time due to production of prolactin by the hypothalmo-pituitary system.

     Menopause

     It is the cessation of  
menstruation as the ovaries cease to react to the gonadotrophic stimulus
  and stop production of the hormones estrogen and progesterone.

     Primary Amenorrhea

     Primary amenorrhea can be  
diagnosed if a patient has normal secondary sexual characteristics but  
no menarche by 16 years of age. If a patient has no secondary sexual  
characteristics and no menarche, primary amenorrhea can be diagnosed as
 early as 14 years of age.

     Causes

     

  1. Hyperprolactinemia
             
             (Prolactin = 100 ng per mL)

    • Altered metabolism

      • Liver failure
      • Renal failure

</li>

</li>




           <li>Ectopic production

  • Bronchiogenic (e.g. carcinoma)
  • Gonadoblastoma
  • Hypopharynx
  • Ovarian dermoid cyst
  • Renal cell carcinoma
  • Teratoma

          Breast feeding
Breast stimulation
Hypothyroidism</li><li>Medications

  • Oral contraceptive pills
  • Anti psychotics
  • Anti depressants
  • Anti hypertensives
  • H2 receptor blocker
  • Opiates

                       Prolactin >100ng/mL

  • Empty sella syndrome
  • Pituitary adenoma

       </li><li>Hypergonadotropic hypogonadism

  • Gonadal dysgenesis

    • Turner's syndrome
    • Other

               </li>
  • Postmenopausal ovarian failure
  • Premature ovarian failure

    • Autoimmune
    • Chemotherapy
    • Galactosemia
    • Genetic
    • 17-hydroxylase deficiency syndrome
    • Idiopathic
    • Mumps
    • Pelvic radiation

               </li>

       </li><li>Hypogonadotropic hypogonadism

  • Anorexia or bulimia nervosa
  • Central nervous system tumor
  • Constitutional delay of growth and puberty
  • Chronic illness

    • Chronic liver disease
    • Chronic renal insufficiency
    • Diabetes
    • Immunodeficiency
    • Inflammatory bowel disease
    • Thyroid disease
    • Severe depression or psychosocial stressors

               </li>
  • Cranial radiation
  • Excessive exercise
  • Excessive weight loss or malnutrition
  • Hypothalamic or pituitary destruction
  • Kallmann syndrome
  • Sheehan's syndrome

       </li><li>Normogonadotropic

  • Congenital
  • Androgen insensitivity syndrome
  • Müllerian agenesis
  • Hyperandrogenic anovulation
  • Acromegaly
  • Androgen-secreting tumor (ovarian or adrenal)
  • Cushing's disease
  • Exogenous androgens
  • Nonclassic congenital adrenal hyperplasia
  • Polycystic ovary syndrome
  • Thyroid disease
  • Outflow tract obstruction
  • Asherman's syndrome
  • Cervical stenosis
  • Imperforate hymen
  • Transverse vaginal septum

       </li><li>Other

  • Pregnancy
  • Thyroid disease

     
                                                                                           
Evaluation of a Case of Primary Amenorrhea
     Secondary amenorrhea

     Secondary amenorrhea is the  
absence of menstruation for three months in women with previously normal
  menstruation and for nine months in women with previous
oligomenorrhea.   Secondary amenorrhea is more common than primary
amenorrhea.

     Causes

     After pregnancy, thyroid  
disease, and hyperprolactinemia are eliminated as potential diagnoses,  
the remaining causes of secondary amenorrhea are classified as

     

  1. Normogonadotropic amenorrhea

    • Hyperandrogenic anovulation
    • Acromegaly
    • Androgen-secreting tumor (ovarian or adrenal)
    • Cushing's disease
    • Exogenous androgens
    • Nonclassic congenital adrenal hyperplasia
    • Polycystic ovary syndrome
    • Thyroid disease
    • Outflow tract obstruction
    • Asherman's syndrome

</li>

</li>

       <li>Hypogonadotropic hypogonadism

  • Anorexia or bulimia nervosa
  • Central nervous system tumor
  • Chronic illness

    • Chronic liver disease
    • Chronic renal insufficiency
    • Diabetes
    • Immunodeficiency

               </li>
  • Excessive exercise
  • Excessive weight loss or malnutrition
  • Hypothalamic or pituitary destruction
  • Sheehan's syndrome

      </li><li>Hypergonadotropic hypogonadism

  • Gonadal dysgenesis
  • Postmenopausal ovarian failure
  • Premature ovarian failure

    • Autoimmune
    • Chemotherapy
    • Galactosemia
    • Genetic
    • 17-hydroxylase deficiency syndrome
    • Idiopathic
    • Mumps
    • Pelvic radiation

    </li>

     Treatment

                                                           






     
     
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           






Special Investigations to Corroborate Clinical Diagnosis





Probable diagnosis
           





Investigations
           






Findings
           
Mullerian agenesisLaparoscopy

             Karyotype
               IVP
Uterus- absent
             Tubes-present
             Ovaries-normal
             46XX
             Urinary tract abnormalities
             (30%)
Unresponsive endometriumProgesterone challenge test
             HSG
Negative
             Normal uterine activity
Uterine synechiaeProgesterone challenge test
             HSG
             Hysteroscopy
Negative
             Honeycomb appearance
             Direct visualization
TuberculosisBlood-ESR
             Chest X Ray
             Mantoux test
             Endometrial biopsy
Raised
             Positive findings
             Usually positive
             Positive lesion may be detected
Hypogonadotropic HypogonadismProgesterone challenge test
             Serum gonadotropins
Positive
             Low<5mIU/mL
Primary ovarian failureKaryotype
             Serum gonadotropins
             Ovarian biopsy
46XX
             Elevated >40mIU/mL
             Follicle(-) or ( )
             -resistant ovarian syndrome
Turner syndromeKaryotype
             Laparoscopy
45XO  or 45 XO/46XX
             Streak gonads
Androgen insensitivity syndromeKaryotype
             Gonadal biopsy
46 XY
             Testicular structure
Androgenital syndromeKaryotype
             Serum hydroxyl progesterone
             Urinary preganetriol
46 XX
             Elevated (>8ng/Ml)
Thyroid dysfunctionSerum TSH
             T3, T4
Elevated
             Lowered
DiabetesBlood sugarElevated
     The general treatment includes
 correction of errors in diet, working conditions, home environment,
the   use of leisure and reduction of weight in case of obesity. In a
large   number of cases in which the cause of amenorrhea is not an
organic   disease, it cures itself spontaneously. Such an outcome should
always be   awaited before starting hormonal therapy or other special
treatment.   Hormonal therapy is instituted depending on the underlying
disorder.

                                                                                                                                                                                                                                                                                                                                                                                                                                       
Hormone




Disorder
ThyroidHypothyroid
CortcosteroidCongenital adrenal hyperplasia
Cyclical estrogen and progesteronePrimary amenorrhea, Premature ovarian failure
ClomiphenePCOS, post pill amenorrhea, Chiari frommel syndrome
GonadotrophinsInfertility due to failed pituitary function and responsive ovaries
GnRH agonistsHypothalmic cause or cause in cerebral cortex
l-dopamineHyperprolactenemia
BromocriptineHyperprolactenemia, Pitutary tumor
     Surgical Treatment

     Wedge resection or laproscopic
 laser ablation of ovaries is practiced in patients with PCOD who do
not   respond to medical treatment.

     Postmenopausal Bleeding

     Postmenopausal bleeding is  
vaginal bleeding of any amount occurring six months or more after the  
menopause. It suggests cervical or uterine body cancer (up to 25%).  
Other causes include polyps, atrophic vaginitis, endometrial hyperplasia
  and urethral caruncle. Care has to be taken with women on HRT who
have   irregular bleeding – they require investigation.

     Early referral is usually  
indicated with a view to a diagnostic procedure. If bleeding recurs  
despite curettage, hysterectomy should be performed since early cancer  
of the uterus may be missed.

     When to Refer

  • To exclude intrauterine pathology.
  • The patient does not respond to initial therapy.
  • There is evidence of underlying disease, e.g. endometriosis, SLE.
  • Surgery is indicated (minor or major).

     Practice Tips:

  • Non menstrual bleeding suggests cancer   until proved other wise: it may be Post coital



    (cervical cancer); Inter   menstrual (common with progesterone only pill
    ;Post menopausal (endo   metrial cancer).
               
             

  • Think of foreign body especially IUCD, if there is an IUCD remove it.
  • Hysteroscopy is more effective than curettage.

     References:

1. General practice by Dr. John Murtagh

   2. Shaws text book of gynaecology

============
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