Menstrual Function/Dysfunctions

Anitha Mullangi, MD, MHCM, CPE, FAAFP

Chief Medical Officer,

St. Johns WellChild and Family Center

Board of Directors, NRIVA

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Disclaimer

This is an information session onlyPlease talk to your doctor for all diagnosis and treatment options

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Phases of Menstrual Cycle

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Menstruation The average age for the onset of menstruation 12.4

years old.

The usual average range of age of onset is 9-17 years

old.

The average interval in between cycles is 28 days.

Cycles that range from 21-35 days is also normal.

The average duration of menstrual flow is 2-7 days.

The average amount of menstrual flow is 30-80 mL.

The normal color of menstrual flow is dark red, which is

a combination of blood, mucus, and endometrial cells.

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Stages of Menstrual Cycles

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Menarche

• Physical changes that occur during puberty in girls

• First sign- Development of breasts- Between the ages of 8-13 yrs

• Appearance of hair in the armpit.

• Widening of hips and appearance of pubic hair. ...

• Growth spurt. ...

• Onset of menstruation.

• It is the first period in a girl’s life begins about 2 to 2½ years after her first signs of puberty (sometimes pubic hair comes first)

• Usually occurs at around 12 years of age

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PMSPremenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

• Affect up to 12% of women, can occur anytime between menarche and menopause

• Not associated with age, educational achievement, or employment status

• Cyclical nature of symptoms- Angry outbursts, anxiety, confusion, depression, irritability, abdominal bloating, breast pain/swelling, headaches, weight gain

• Symptoms that cause significant impairment starting after the ovulation (luteal phase) but resolve shortly after the periods

• Treatment• Select serotonergic antidepressants are first-line treatments

• Cognitive behavior therapy

• Oral contraceptives

• Calcium supplementation

• Quetiapine (Seroquel) 8

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Amenorrhea

• Primary amenorrhea - failure to reach menarche. • if there is no pubertal development by 13 years of age,

• if menarche has not occurred five years after initial breast development, or

• if the patient is 15 years or older.

• Secondary amenorrhea- cessation of menses in the absence of pregnancy, lactation, cycle suppression with pills or menopause.• previously regular menses for three months or

• previously irregular menses for six months

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Abnormal Uterine Bleeding (AUB)

• Effects 14–25% of women of reproductive age• It can impact a woman’s daily activity, health, quality of life• Can impact a woman’s social and sexual life.

Abnormal uterine bleeding:

• Bleeding or spotting between periods

• Bleeding or spotting after sex

• Heavy bleeding during your period

• Menstrual cycles that are longer than 38 days or shorter than 24 days

• “Irregular” periods in which cycle length varies by more than 7–9 days

• Bleeding after menopause

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Definitions

Polymenorrhoea- frequency less than 24 days, but regular intervals

Menorrhagia (Heavy Menstrual Bleeding)- heavy or prolonged period at regular intervals

Metrorrhagia- periods at irregular intervals

Menometrorrhagia- a combination of Menorrhagia and Metrorrhagia

- heavy or prolonged period at irregular intervals

Hypomenorrhoea- scanty or very light periods

Oligomenorrhea- infrequent menstrual periods beyond 35 days

Intermentstrual Bleeding- occasional bleeding in between regular periods

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Causes

Causes in the UterusPregnancyPolypAdenomyosis EndometriosisLeiomyoma Endometrial hyperplasiaInfectionsCancer in the uterus, cervix

Causes in the OvaryAnovulationPCOSOvarian CystsOvarian cancer/tumor

Endocrine disordersThyroid diseasesUncontrolled DiabetesHyperprolactinemiaEating disordersExcessive sports

Bleeding disordersCoagulopathyPlatelet disordersVon Willebrand disease Anemia

Other causesMedicationsPerimenopauseContraceptive methods

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Causes in the Uterus

PregnancyAdenomyosis EndometriosisFibroid PolypEndometrial hyperplasiaInfectionsCancer in the uterus, cervix

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Signs and symptoms

• AUB, usually in 40s to 50s

• Painful, cramping and/or heavy periods

• Enlarged uterus

Diagnosis

• Transvaginal Ultrasound

• MRI

Treatment

• Nonsteroidal Anti-inflammatory drugs

• Hormonal therapy

• Uterine artery embolization

• Endometrial ablation

• Hysterectomy

• Menopause

Adenomyosis“The tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus”

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Endometriosis

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The endometrium grows outside your uterus. Endometriosis most commonly involves ovaries, fallopian tubes and the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond pelvic organs.

Signs and Symptoms:

• Seen in-10 percent of women.

• Pelvic pain. Painful periods and pain with intercourse

• Pain with bowel movements or urination- especially during periods.

• Excessive bleeding- heavy periods or bleeding between periods

• Infertility-40% of women

• Other symptoms- fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

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Endometriosis- Risk Factors

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• Never giving birth (Nulliparous)

• Increases with increased exposure to endometrial material-

• Short menstrual cycles or longer bleeding days

• Starting your period at an early age

• Menopause at an older age

• Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen

• Low body mass index

• Family history of endometriosis

• Uterine abnormalities

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Endometriosis- Management

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Medical management

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Hormonal medications

• birth control pills

• Depo Provera injections/ tablets

• Gonadotropin-releasing hormone agonists

• Hormonal IUDs- Mirena

Surgical Treatment• Surgery to remove the

nerves causing the pain• Surgical ablation• Removal of Uterus and

Ovaries

Diagnosis

• Pelvic exam

• Laparoscopy- direct visualization of lesions with histologic confirmation

• MRI

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Leiomyoma - FibroidsSigns and symptoms• most common benign tumors in women of reproductive age

• Up to 80% of women by 50 years of age

• Painful, cramping and/or heavy periods

• Pelvic pressure/heaviness, low back pain

• Urinary frequency, urgency, retention

• Constipation

• Pain with intercourse

• Enlarged uterus/ abdominal enlargement

• preterm labor, obstruction of labor, Pregnancy loss, Infertility

Increased Risk• Family history

• Increase in age, African descent

• Early menarche (before 10yrs)

• Never been pregnant

• Obesity

Decreased risk • Increased pregnancies • Late menarche (older than 16 yrs)• Smoking• Use of oral contraceptives

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Fibroids

Annual direct treatment costs $4.1–9.4 billion,

Indirect costs-lost work hours $1.55–17.2 billion

Classification

Uterine fibroids are classified based on location

on the uterus

Diagnosis

• Transvaginal Ultrasound

• Sonohysterography/ Hysteroscopy

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Fibroids- TreatmentTreatment should satisfy four goals

• relief of signs and symptoms

• sustained reduction of the size of fibroids

• maintenance of fertility

• avoidance of harm

Medical Treatment

• Nonsteroidal Anti-inflammatory drugs

• Tranexamic acid

• Gonadotropin-releasing hormone agonists , e.g. Lupron

• Oral Contraceptives

• Levonorgestrel-releasing intrauterine system (Mirena)

• Selective progesterone receptor (SPRMs)

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Fibroids- surgerySurgical Treatment

The symptoms and treatment options are affected by the size, number, and location of the tumors

• Uterine artery embolization

• Magnetic resonance guided focused ultrasound surgery

• Myomectomy

• Hysterectomy

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Diagnosis

• Transvaginal Ultrasound

• Hysteroscopy/ Sonohysterography

Treatment

• Watchful waiting

• Surgical removal-• Endometrial polypectomy/ ablation

Endometrial Polyps

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Cervical cancer screening

Age Screening needed

Below 21 years No test needed

21-29 years Pap Smear every 3 years

HPV testing is not recommended

30-65 years Pap Smear every 3 years

Pap Smear and an HPV test (co-testing) every 5 years

Over 65 years Stop cervical cancer screening if:• no history of moderate or severe abnormal cervical cells or cervical cancer,

and• three negative Pap test results in a row or • two negative co-test results in a row within the past 10 years, with the most

recent test performed within the past 5 years.• Hysterectomy with cervix removed for a non- cancer

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• Anovulation

• PCOS

• Ovarian Cysts

• Ovarian cancer/tumor

Causes in the Ovary

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PCOS

Symptoms of PCOS

•Abnormal Menstrual patterns

•Oligomenorrhea (> 35days but < 6 months)

•Amenorrhea (> 6 months after cycles establsied)

•Hirsutism- increase hair in male distribution pattern

•Infertility

•Obesity and metabolic syndrome- 50%

•Sleep Apnea

Polycystic ovaries

2003-Rotterdam criteria for diagnosis

PCOS is the most common endocrine disorder among women between the ages of 18 and 44

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Signs of PCOS

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PCOS Labs

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• Life style modifications- Diet and exercise

• Hormonal Contraceptives- Estradiol/Cyproterane Acetate

• Ovulation Induction- Clomiphene

• Hirsutism- Spironolactone, Eflornithine (Vaniqa), Finasteride, Flutamide

• Metformin, Letrozole

• Bilateral Ovarian drilling

PCOS Management

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Endocrine disorders

• Thyroid diseases

• Uncontrolled Diabetes

• Hyperprolactinemia

• Eating disorders

• Excessive sports

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Thyroid disease

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• No periods or decreased periods or increased periods• Anovulation or no egg formation (Infertility)• Hypertension• Hypothyroidism (does not make enough thyroid hormones)

• Weight gain, dry skin, thinning of hair, constipation, increased sleep,

• Feeling cold, tired, down, slow heart rate, hoarse voice• Thyroid hormone decreases• TSH increases• Prolactin may increase

• Hyperthyroidism• Weight loss, palpitations, trouble sleeping, increased sweating• Feeling anxious, hungry, weakness• Thyroid hormone increases• TSH decreases• Can cause Osteoporosis

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• Bleeding Disorders• Medications

• Seizure medications• Antipsychotics

• Perimenopause• Contraceptive agents

• OC pills• IUD• Nexplanon

Other causes

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Bleeding Disorders

Bleeding disordersCoagulopathyPlatelet disordersVon Willebrand disease Anemia

Test for bleeding disorder in adolescents and in

women with one or more of the following risk factors:

• family history of bleeding disorder

• menses lasting seven days or more with flooding

or impairment of activities with most periods

• history of treatment for anemia

• history of excessive bleeding with tooth extraction,

delivery or miscarriage, or surgery

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No menstrual periods for 12 consecutive months and

No other biological or physiological cause can be identified.

Average age of onset: 51 years

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Menopause

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• Irregular Periods

• Physical changes

Weight gain, wrinkles, hair growth on lips, chin, chest

• Emotional symptoms

Mood disturbances, irritability, sleeplessness

• Urogenital atrophy

Vaginal dryness, dyspareunia, vulvar itching, frequent urination, urgency, and recurrent urinary infections

• Incidence 10-40% of menopausal women

• Vasomotor Symptoms

Hot flushes, extreme heat in the upper body (face), sweating, flushing, chills, clamminess, anxiety, palpitations

• 87% women report daily; 33% report > 10 flushes per day

• Symptom lasts 6 mos- 2 years

Symptoms of Menopause

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Women with a uterus

• Hot flashes are the most common indication for hormone therapy.

• Cyclic therapy: • Estrogen : conjugated, micronized, transdermal (Vivel Dot)• Medroxyprogesterone Acetate (Provera) • Estrogen is taken every day, and progestin is added for several days

each month or for several days every 3 months or 4 months.

• Continuous therapy: • Estrogen and progestin are taken every day• Combined E2/Progestin (Prempro/Premphase)

• Estrogen + SERM: DUAVEE

• Side Effects: breast cancer, increased risk of heart disease, stroke, blood clots

• Advantages: Reduced hip fractures

HRT Formulations

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Hormone Replacement Therapy

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Natural remedies for Menopausal symptoms

Black cohosh: Black cohosh is used to help treat menopausal symptoms, such as hot flashes.

Red clover: has phytoestrogens which are similar to estrogen.

Soy: Soybeans make isoflavones, a type of phytoestrogen.

Relaxation and stress-reduction techniques: Yoga, tai chi, and acupuncture may help reduce

menopause symptoms, including sleep and mood problems, stress, and muscle and joint pain.

Hypnosis: helped decrease hot flashes by 74%

Kegel exercises: to strengthen pelvic floor muscles and reduce incontinence episodes.

Vaginal lubricants and moisturizers: Only water-soluble products should be used, eg:

Ospemifene (Osphena)

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Foods for Menopausal Symptoms• Water• Calcium- milk and nonfat yogurt, and calcium supplements, broccoli, and legumes• vitamin D supplements• Whole grains. Some whole grains, such as steel-cut oatmeal, quinoa, barley, and brown rice• Iron-lean cuts of beef, eggs, iron-rich cereals, and grain• Soy- edamame, tofu, and other soy foods• Flaxseed- fiber, estrogen like compounds• Almonds- magnesium, vitamin E complex, and riboflavin• Cooked dried beans and peas, such as black beans, kidney beans, lentils, split peas, and garbanzos• Iodine- cod, dried prunes, canned tuna, cranberries, green beans, and navy beans.• Fiber- whole-grain breads, cereals, pasta, rice, fresh fruits, and vegetables• Omega 3 fatty acids

What to avoid• Alcohol, sugar, caffeine, and spicy foods, which can trigger hot flashes• High fat foods

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Period Management

• Use more absorbent pads/tampons during heavy flow• Can use less absorbent pads/tampons during lighter flow• Change pads every 3-6 hours; tampons every 2-4 hours• Risks of wearing a single pad/tampon too long:

• Vaginal yeast infection (fungal infection)• Other bacterial infections• Rash or skin irritation• Bacterial odor from the blood• Toxic Shock Syndrome (TSS) with superabsorbent tampons

• Normal to pass blood, tissue, and blood clots during menstruation• Normal for periods to become irregular and lighter as you near menopause • If your flow is too light or too heavy, consult your gynecologist to rule out

other problems.

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