Abnormal Uterine Bleeding and the Menstrual Cycle

Susana Martinez

What is ‘normal’?O A ‘normal’ menstrual pattern is

associated with a monthly bleed (every 21-35 days) with duration of seven days or less.

O A blood loss of 80mls or less, is regarded as being in the normal range

Menstrual cycle ~ overview

O A regular menstrual patterns depends on the presence of a functioning reproductive hormone feedback system which includes the hypothalamus, anterior pituitary gland and ovaries, as well as normal uterine and vaginal anatomy.

Menstrual abnormalities

O Menstrual abnormalities include irregular or absent periods, heavy or prolonged menstrual loss (for 3 cycles or more), inter-menstrual and post-coital bleeding, dysmenorrhoea and pre-menstrual disorders.

AmenorrhoeaO Primary amenorrhoeaO The absence of onset of

menstruation – is regarded as abnormal by the age of 14 years in girls with no other secondary sexual development, and 16 in girls with normal secondary sexual development.

Causes of primary amenorrhoea

O Anatomical abnormalities (imperforate hymen, congenital absence of uterus or vagina)

O Chromosonal anomalies causing failure to initiate puberty

O Hypogonadotrophic hypogonadism (failure to switch on puberty)

O PCOSO Chronic illness or low body mass (or

excessive exercise)

Secondary amenorrhoea

O The cessation of menstruation for a period of six months, after regular cycles have been established.

Causes of secondary amenorrhoea

O Hyphothalamic-pituitary reasons includes:

O Weight loss (BMI <19 unlikely to have regular menstrual cycle)

O Excessive exerciseO ObesityO Secondary to medication: hormonal

contraception, antipsychotics, opiates, chemotherapy

Causes of secondary amenorrhoea

O Ovarian, uterine or vaginalO Polycystic Ovarian Syndrome (PCOS)O Premature ovarian failureO Other causesO Thyroid hormone deficiency or

excessO Severe generalised disease

InvestigationsO Investigate after 6 months of

secondary amenorrhoea which is not secondary to contraceptive use such as an implant, Depo injection or Mirena.

O Pregnancy testO FSH, LH, Prolactin and TSH, oestrodialO Testosterone levelsO Consider pelvic/transvaginal ultrasoundO Consider bone density scan

Management of amenorrhoea

O Primary amenorrhoeaO Refer to a specialist for further

investigationO Secondary amenorrhoeaO Referral to specialist (gynaecologist

or endocrinologist) where diagnosis or management is not clear after initial investigation, and if patient is concerned about fertility.

DysmenorrhoeaO Dysmenorrhoea is a cyclical lower

abdominal or pelvic pain occuring either before or during menstruation, or both.

O Prevalence is difficult to estimate, but it is thought that dysmenorrhoea affects up to 70% of women at some time during reproductive age.

EndometriosisO Endometriosis is defined as the

presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction.

O Condition found in women of reproductive age, from all ethnic and social groups

O Estimated prevalence is up to 10%.O Endometriosis often begins in

adolescence

Adbormal Uterine Bleeding (AUB)

O Abnormal uterine bleeding includes:O Heavy menstrual bleeding (HMB –

previously called menorrhagia)O Intermenstrual bleeding (IMB) and

post-coital bleeding (PCB)

Management of HMBO IUS (Mirena)O Combined COC (Qlaira)O Tranexamic acidO Nonsteroidal anti-inflammatory drugs

(NSAIDs)O Progestogens (norethisterone (15mg)

daily from days 5-26 of menstrual cycle or long acting injectable progestogens (DMPA -Depo)