Abnormalities of the Menstrual Cycle

• Menstrual cycle


  Characteristics vary from woman to woman, normal range is 21-35 days, bleeding for up to 7 days, mild to moderate cramping
• Abnormal uterine bleeding


  Any departure from the normal menstrual cycle, including too much bleeding, too little bleeding, or inappropriate unscheduled bleeding
• Dysmenorrhea


  • Pain and cramping during menstruation that interferes with normal activities and requires medication
• Primary dysmenorrhea


  Idiopathic menstrual pain without identifiable pathology
• Secondary dysmenorrhea


  Painful menses due to underlying pathology (endometriosis, fibroids, adenomyosis, PID, cervical stenosis)
• Diagnosis of primary dysmenorrhea

  Based on history and absence of organic causes, most common misdiagnosis is endometriosis
• Cervical stenosis


  Causes dysmenorrhea by obstructing blood flow during menstruation, can be congenital or secondary to scarring
• Pelvic adhesions


  Can cause dysmenorrhea, often due to history of pelvic infections or prior pelvic surgery
• Premenstrual syndrome (PMS)


  Constellation of physical and/or behavioral changes that occur in the second half of the menstrual cycle
• Premenstrual dysphoric disorder (PMDD)


  More severe variant of PMS
• About 75% of women suffer from some recurrent PMS symptoms, 30% report significant problems, 5% are incapacitated by PMDD</b>
• Pathogenesis of PMS/PMDD


  Likely multifactorial, including abnormalities in estrogen-progesterone balance, disturbance in renin-angiotensin-aldosterone pathway, excess prostaglandin and prolactin production, and psychogenic factors
• Dysfunctional uterine bleeding (DUB)


  Idiopathic heavy and/or irregular bleeding that cannot be attributed to another cause
• The most common cause of DUB is anovulation or oligoovulation
• Typical patterns of abnormal uterine bleeding

  • Menorrhagia
  • Hypomenorrhea
  • Metrorrhagia
  • Menometrorrhagia
  • Oligomenorrhea
  • Polymenorrhea
  • Amenorrhea, secondary
  • Amenorrhea, primary
  • Dysfunctional uterine bleeding
• Menorrhagia


  Regularly timed menstrual cycles but the flow is either excessive in its duration (>7 days) or its volume (>80 mL/cycle)
• Hypomenorrhea


  Regularly timed menses but an unusually light amount of flow
• Metrorrhagia


  Bleeding that occurs between regular menstrual periods, usually less than or equal to normal menstrual volume
• Menometrorrhagia


  Excessive (>80 mL) or prolonged bleeding at irregular intervals
• Oligomenorrhea


  Periods greater than 35 days apart
• Polymenorrhea


  Regular periods that occur less than 21 days apart
• Amenorrhea, secondary


  No menses for 6 or more consecutive months
• Amenorrhea, primary


  No menses by age 14 in the absence of secondary sexual characteristics or no menses by age 16 in the presence of secondary sexual characteristics
• Dysfunctional uterine bleeding


  Idiopathic heavy and/or irregular bleeding with no identifiable causes
• The PALM-COEIN system classifies abnormal uterine bleeding by both the pattern and the etiology of the bleeding
• PALM represents the structural causes of abnormal uterine bleeding including Polyps, Adenomyosis, Leiomyomas, and Malignancy and hyperplasia
• COEIN delineates the nonstructural causes including Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic and those etiologies that are Not yet classified
• Evaluation of abnormal uterine bleeding

  1. Careful history and physical examination

  2. Diagnostic tests to determine underlying etiology
• Laboratory evaluation for abnormal uterine bleeding

  • Pregnancy test
  • TSH
  • PRL
  • FSH
  • CBC
  • PT/PTT
  • Factor VIII
  • von Willebrand factor antigen and activity
• Women age 45 or older with abnormal uterine bleeding should undergo endometrial biopsy to rule out endometrial hyperplasia and cancer
• Obese patients with prolonged oligomenorrhea should also undergo endometrial biopsy even if they are younger than 45 years
• Diagnostic tests for abnormal uterine bleeding

  • Pelvic ultrasound
  • 3D ultrasound
  • Sonohysterogram
  • Hysterosalpingogram
  • Hysteroscopy
  • Dilation and curettage (D&C)
• Treatments for abnormal uterine bleeding

  • Hormonal management
  • Tranexamic acid
  • Uterine artery embolization
  • Myomectomy
  • Endometrial ablation
  • Hysterectomy
  • Polypectomy
  • Progestin therapy
  • Thyroid hormone replacement
  • Dopamine agonists
  • Combined estrogen/progestin pills, patch or ring, or cyclic progestin
• Dysfunctional uterine bleeding


  A diagnosis of exclusion, most commonly due to anovulation where the ovary produces estrogen but no corpus luteum is formed, and thus no progesterone is produced
• Dysfunctional uterine bleeding is most likely to occur with anovulatory cycles, such as during adolescence, perimenopause, lactation, and pregnancy
• Dysfunctional uterine bleeding (DUB)


  A diagnosis of exclusion when no pathologic cause of abnormal uterine bleeding is identified
• DUB


  • Most patients with DUB are anovulatory
  • Endometrium continues to proliferate until it outgrows its blood supply, breaks down, and sloughs off in an irregular fashion
• DUB is most likely to occur with anovulatory cycles and thus is most common during times in a woman's life when she is most likely to be anovulatory such as adolescence, perimenopause, lactation, and pregnancy
• Pathologic anovulation occurs in hypothyroidism, hyperprolactinemia, hyperandrogenism, and POI/PMOF
• Diagnosis of DUB


  1. History

  2. Physical examination

  3. Laboratory tests

  4. Imaging to rule out other causes