[duke] mmed menstrual problems (amended)

8/4/2019 [Duke] MMED Menstrual Problems (Amended)

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DR TAN THIAM CHYEDR TAN THIAM CHYE

ConsultantConsultant

Dept of Obstetrics andDept of Obstetrics and

GynaecologyGynaecology

Assistant ProfessorAssistant Professor

Duke-NUS Graduate Medical SchoolDuke-NUS Graduate Medical School

YLL School of Medicine, NUSYLL School of Medicine, NUS

Menstrual

Disorders


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PRIMARY AMENORRHOEAPRIMARY AMENORRHOEA

Never experienced menstrual period by age16

Definition


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Primary amenorrhoea

Constitutional delaySimilar history in mother or

sisters

Chronic systemic

diseasesEg diabetes mellitus,

renal disease

Primary ovarian failureCould be due to chemotherapy

or radiotherapy

Chromosomal disorders

Turner syndrome45, X0

Developmental disorders

Rokitansky-Kuster Hauser

syndromeFailure of Mullerian duct

developmentCongenital absence of uterus and

upper vaginaNormal 46 XX karyotype

Vaginal agenesis

XY female

Swyer syndrome46 XY karyotypePure gonadal dysgenesis

No androgens or Mullerianinhibitory factorsAllows Mullerian duct to

develop into fallopian tubes,

uterus and upper vagina

Complete androgen insensitivity

syndrome

46 XY karyotypePhenotypically femaleTall with good breast developmentNormal female external genitaliaSparse pubic and axillary hairNo uterus and upper vagina


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ManagementManagement

Refer OBGYN for investigations and management of primary amenorrhoea

For constitutional delay, no treatment is needed except reassurance

For chromosomal disorders and primary ovarian failure, small dose of ethinyl oestradiol

1g daily can be started for 6 months, increasing to 2, 5, 10 and eventually 20 g withincrements at six monthly intervals. This is then followed by combined oral contraceptive

pills.

For vaginal and mullerian agenesis, vaginal reconstruction is necessary. This could be

achieved by vaginal dilators or surgical procedures like Williams vulvo-vaginoplasty,

McIndoes procedure or skin graft.

For the XY female, counseling with the parents is important to discuss on psychological

issues of gender of rearing and gender identity. Management includes gonadectomy as

the dysgenetic testes have a high lifetime risk of malignancy (30%).


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SECONDARY AMENORRHOEASECONDARY AMENORRHOEA

Cessation of menses for 6 months

DEFINITION


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Secondary amenorrhoea

Pregnancy

Hypothalamic dysfunction

Extreme weight gain/

lossExcessive exercise

Pituitary dysfunction

Prolactinoma

(commonest)Sheehan syndromePituitary adenoma

Craniopharyngioma

Hyperthyroidism

Ovarian dysfunction

Polycystic

ovarian

syndrome

(PCOS)

MenopausePremature ovarian failure< 40 years old

Resistant ovary

syndrome


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Evaluation: History Weight loss or gain,

Psychological dysfunction/ emotional stress

Presence of galactorrhoea

Symptoms of thyroid disorder Hirsutism, change of voice,

Menopausal symptoms

Family history of possible genetic anomalies

History of uterine/cervical surgery/ medication

Sexual/contraceptive practice


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Investigations:

1. Urine pregnancy test to exclude pregnancy

2. Follicular stimulating hormone (FSH) on Day 2-3 of mensesSuggests ovarian failure if > 30 IU/LLow level suggests hypothalamic/ pituitary dysfunctionReversal of LH/FSH ratio > 3:1 suggests PCOS

. Serum prolactin level

Hyperprolactinaemia could cause secondaryamenorrhoea

.Thyroid function test

Hyperthyroidism could cause secondary amenorrhoea

. Progestogen challenge test

Give 5mg oral norethisterone bd for 5 days

If there is withdrawal bleeding, there is presence of oestrogen and would mean that the patient would need cyclicalprogestogen for withdrawal bleeding to protect the endometrium from endometrial hyperplasia and carcinoma

If there is no withdrawal bleeding, then combined oral contraceptive pill would be needed


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DYSFUNCTIONAL UTERINE BLEEDINGDefinition

The normal menstrual cycle lasts between 21 and 35 days with menstrual flow lasting2-7 days.

Any disturbance in the menstrual cycle or flow pattern is termed as dysfunctionaluterine bleeding (DUB) after excluding systemic and pelvic pathological causes.

Steps in workup of DUB

(1)Look for pallor. If pale, check haemoglobin level.(2)

Ensure that the patient is haemodynamically stable. Quantify severity ofbleeding eg. number of pads used / day and presence of blood clots or episodesof flooding

(3)Clinical examination to exclude cervical lesion and do a PAP smear if last PAPsmear >1 year ago


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Perform urine pregnancy test to exclude pregnancy related problems (threatened

miscarriage, inevitable miscarriage or ectopic pregnancy)

If there are bleeding tendencies, exclude blood dyscrasias for adolescents (13-18

years old)

If there are symptoms of thyroid disorder or galactorrhoea, check thyroid function

test or prolactin level

Perform pelvic ultrasound scan to exclude pelvic pathology (fibroids/ adenomyosis)

Perform endometrial assessment (if 40 years old or failed conventional medical

treatment) to exclude endometrial hyperplasia or carcinoma

INVESTIGATIONSINVESTIGATIONS


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Goals of RxAlleviate acute bleeding. Give IM progesterone 100 mg stat Prevent future episodes of noncyclic bleeding aim to give a bleed which is

predictable in timing and amount Decrease risk of long term complications (eg development of endometrial

cancer)

Refer OBGYN for endometrial assessment and further treatment if failedconventional initial treatment or age 40 and above

NSAIDs (egmefenamic acid500mg tds)

Common medical treatments

Antifibrinolyticagents egTranexamic acid(500mg-1g tds)-can cause venousthrombosis

Cyclic progestogen (at least 10-14days per cycle)Norethisterone 5-10mg bd

Provera 10mg bd

Combined oestrogen and

progestogen preparation Combined oral contraceptive

pill

Progyluton (containing 11 tabs

of estradiol valerate 2 mg each

and 10 tabs of 2mg estradiol

valerate and 0.5mg norgestrel


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OOther hormonal medical treatments

MIRENA/ Levonorgestrel (LNG)-releasing Intrauterine System

Releases 20ug of LNG daily which affects the endometrium locally

Lasts 5 years

Low local hormonal effect in the endometrium which provides shorter and lighter menses and reduces

dysmenorrhea

20% amenorrhoea after 1 year

20% intermittent per-vaginal spotting in 1st 6 months

Lower risks of pelvic inflammatory disease and ectopic pregnancy compared with copper-IUCD


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Cyclical sequential combined hormonal replacement therapy with 2mg

estradiol valerate for first 11 days and 2mg estradiol valerate with 0.5mg

norgestrel for next 10 days

Regulates menstrual cycle and does not affect endogenous hormone

production

Does not interfere with ovulation

Can be used by pre- and peri- menopausal patients

PROGYLUTON


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Depot ProveraIntramuscular Depot Provera 150mg every 3 monthly

Induce endometrial atrophy and amenorrhoea

Irregular bleeding in first 3 months

Side-effects: abdominal bloating, breast tenderness, weight

gain, depression, water retention


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Gonadotrophin Releasing Hormone analogue (GnRHa)

Continuous treatment with GnRHa causes down-regulation of pituitary

gland and subsequent decrease in gonadotrophins and ovarian steroids

Causes amenorrhoea (90%)

Side-effects are related to hypo-oestrogenism and post-menopausal in

type (hot flushes, insomnia, mood swings)

Not recommended for more than 6 months of continuous usage due to the

risk of osteoporosis unless with hormonal add-back therapy

Subcutaneous injection Zoladex (Goserelin) 3.6mg monthly,

subcutaneous injection Lucrin (Leuprorelin) 3.75mg monthly / 11.25mg every

3-monthly, intra-muscular injection Decapetyl (Triptorelin) 3.75mg monthly


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Danazol

Induce amenorrhoea in majority if taken in moderate/ high dose (>

400 mg daily)

If taken at low dose (200 - 400 mg daily) it will induce amenorrhoea

in some while others may experience light but often unpredictable

bleed

Masculinising side-effects such as hirsutism, acne, voice change

(irreversible)


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Endometrial ablation

Hysterectomy

Surgical Management


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Amenorrhoea with Depot Provera

Perform urine pregnancy test to exclude pregnancy

Positive

Manage pregnancy

accordingly

Negativee

Reassure as 50% of women have

amenorrhoea while on Depot Provera

DEPOT PROVERA RELATED MENSTRUAL PROBLEMS


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DEPOT PROVERA RELATED MENSTRUAL PROBLEMSDEPOT PROVERA RELATED MENSTRUAL PROBLEMS

Irregular menses with Depot Provera

Perform urine pregnancy test to exclude pregnancy

PositiveManage

pregnancy

accordingly

Negative

Bleeding 6 months Bleeding > 6 months

NSAIDs (eg

mefenamic acid

500mg tds x 10 days)

Conjugated

oestrogen

(Premarin) 0.625

mg OM x 21 days

Reassure as it is common in

35% of women on Depot

Provera


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Case 1Case 1

LMP: Cannot rememberLMP: Cannot remember

Clinically stable parametersClinically stable parameters

UPT positiveUPT positive POC seen at cervical osPOC seen at cervical os


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Pelvic scan:

Empty uterus. ET 9 mm

Adnexae NAD


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Case 1Case 1

Diagnosis: Complete miscarriageDiagnosis: Complete miscarriage

Conservative managementConservative management

Oral augmentin x 1 weekOral augmentin x 1 week


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Case 2Case 2 27 years old.27 years old.

1 X LSCS for CPD (2002).1 X LSCS for CPD (2002).

1 X m/c (2003) evacuation done.1 X m/c (2003) evacuation done.

LMP 31/12/05 & p/v bleeding since then.LMP 31/12/05 & p/v bleeding since then. Was treated as DUB on 23/01/06 in OPD.Was treated as DUB on 23/01/06 in OPD.

NE & Folic acid was given.NE & Folic acid was given.

Fybogel & enema x1.Fybogel & enema x1. Presented to 24 hrs clinic on 24 Jan2006 atPresented to 24 hrs clinic on 24 Jan2006 at1.10am.1.10am.


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Presenting ComplaintsPresenting Complaints

Prolonged PV bleedingProlonged PV bleeding

Since 31/12/05.Since 31/12/05.

2 pads / day2 pads / day

No signs of anemia.No signs of anemia.

LIF pain X 1 dayLIF pain X 1 day

UPT +UPT +


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Initial AssessmentInitial Assessment

In 24 hour ClinicIn 24 hour Clinic

1.1. HR 97 bpm; BP 95/63, Pain score 5/10HR 97 bpm; BP 95/63, Pain score 5/10

2.2. Abdomen soft butAbdomen soft but guarded in LIFguarded in LIF; With; With

lower abdominal fullness. No rebound.lower abdominal fullness. No rebound.

3.3. VE left adnexal tenderness; No cervicalVE left adnexal tenderness; No cervical

excitation.excitation.


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Urgent DI ScanUrgent DI Scan

Mass at left adnexa,Mass at left adnexa,

adjacent to left ovaryadjacent to left ovary

(visualised)(visualised) ring like,ring like,

vascular.vascular. ? Ectopic Pregnancy? Ectopic Pregnancy

HemoperitoneumHemoperitoneum

Empty uterus except forEmpty uterus except forblood clotsblood clots


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In the WardIn the Ward Hb 13.4g/dl; BHCG 387.8IU/L.Hb 13.4g/dl; BHCG 387.8IU/L.

Patient and husband counseled on thePatient and husband counseled on thehigh possibility of an ectopic pregnancyhigh possibility of an ectopic pregnancy

Agreeable for Laparoscopic salpingectomyAgreeable for Laparoscopic salpingectomyKIV cystectomy KIV evacuation of uterus/KIV cystectomy KIV evacuation of uterus/KIV laparotomy.KIV laparotomy.

Risks of op explained.Risks of op explained.


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Operative findingsOperative findings

Haemoperitoneum 200 mlsHaemoperitoneum 200 mls

Ruptured left tubal ectopicRuptured left tubal ectopic

pregnancy 4cmpregnancy 4cm

MIS Left salpingectomyMIS Left salpingectomydonedone

Left ovary normal,right tubeLeft ovary normal,right tube

normalnormal

[duke] mmed menstrual problems (amended)

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