the menstrual cycle a vital sign

THE MENSTRUAL CYCLE
A VITAL SIGN
DR MICHAL YARON
CDC gynécologie pédiatrique et des Adolescentes
Département de gynécologie et pédiatrie
Hôpitaux Universitaires de Genève
1
Causes of Menstrual Irregularity
Pregnancy
Endocrine causes
• Poorly controlled diabetes mellitus
• Polycystic ovary syndrome (PCOS)
• Cushing disease
• Thyroid dysfunction
• Ovarian Insufficiency
• Late-onset congenital adrenal hyperplasia
Acquired conditions
• Stress-related hypothalamic dysfunction
• Medications
• Exercise-induced
• Eating disorders (both anorexia and bulimia)
Tumors
• Ovarian tumors
• Adrenal tumors
• Prolactinomas
Chronic Disease
2
Evaluation
• Discussion
• Gynecological age (âge de la patiente – âge de la
ménarche).
• Evaluation of Bleeding
• Menstrual Calender
• Pregnancy Test
• Labratory Tests as indicated by Menstrual Dysfunction:
• Irregular Bleeding: TSH, Androgens (if hirsutism and modsevere acne) to confirm clinical diagnosis of PCOS by
excluding other causes of hyperandrogenism.
• Amenorrhea: Estradiol, FSH, androgens, PRL, et TSH.
3
HEAVY MENSES
IN ADOLESCENTS
4
INTRODUCTION
What is NORMAL ?
Jennifer Miller – Performance artist NYC
Photograph taken by Annie Leibovitz
5
WHAT IS NORMAL ?
6
SUGGESTED NORMAL LIMITS FOR
MENSTRUAL PARAMETERS
7
EVALUATION
• General adolescent issues
HEADSS
home or housing
education and employment
activities
drugs
• Impact on life
• Menstrual loss
• Focused personal and family history of bleeding
8
EVALUATION OF BLOOD LOSS
Excessive uterine bleeding:
•
•
•
•
•
8 days or more
6 pads/tampons a day
or pad/tampon every 1-2h
Frequency < 21 days
Iron-deficiency anemia
> 80cc
9
GOLD
STANDARD
10
PICTORIAL BLOOD ASSESSMENT CHART
11
PERSONAL and FAMILIAL
HISTORY
• Cutaneous bleeding
(ecchimoses or bruises)
• Bleeding at time of surgery
• Bleeding requiring blood transfusion
• Protracted bleeding post tooth
extraction
• Postpartum bleeding
12
PERSONAL
HISTORY
• Mittelschmerz (ovulation pain)
• Recurrent hemorrhagic CL
• Autoimmune Diseases
13
BLEEDING SCORE
14
BLEEDING SCORE
15
BLEEDING SCORE
BS > 3 = Further evaluation
16
DIFFERENTIAL DIAGNOSIS
HEMATOLOGICAL CAUSES
THROMBOCTOPENIA
3%
- Idiopathic Thrombocytopenic Purpura (ITP)
- other haematological conditions
HAEMOPHILIA CARRIERS
USE OF ANTICOAGUALNT MEDICTION
USE OF ANTI-AGGREGATING AGENTS
FACTOR DEFICIENCIES OR ANTIBODIES
(INHERTIED OR ACQUIRED)
- VW disease
8%
PREVALENCE IN ADOLESCENTS
- Deficit in factor XI
- Liver disease
PLATELET FUNCTION DISORDERS 19%
17
VON WILLEBRAND DISEASE
• Most common inherited bleeding disorder - 1%
• Quantitative (type 1&3) or qualitative (type 2)
deficiency of VWF
Type 1
Type 2
Type 3
60 - 80%
30%
rare
moderate
variant
severe
18
VWD IN WOMEN
► ► ► ► ► ► ► Delay in Diagnosis
• Average time from 1st symptom –Dx
16 (range 10-39 years)
• Average bleeding symptom before Dx
6 (1-19)
• Commonest symptom –Menorrhagia
Kirtava et al 2004, Haemophilia
19
HAEMATOLOGICAL INVESTIGATION
Indications
• Acute menorrhagia – requiring admission
• Menorrhagia since menarche
• Positive bleeding history and/or causing
iron deficiency anaemia
Investigations
Further studies
FBC, , PLT, Ferritin
PT/APTT/Fibrinogen
PFA 100 = Bleeding time
VWF: Ag, CB, RiCof
•Platelet function studies
•Other clotting factors
•FXI – Jewish origin
•Rare disorders –
Consanguineous marriage
20
WORK - U P
In all adolescent:
• US
• Pregnancy Test
In sexually active adolescent:
• Full gynaecological exam
• Cultures for chlamydia and gonorrhea
+ CRP
21
MANAGEMENT OF ACUTE BLEEDING
• Resuscitation and volume replacement
• Haemostatic agent
• Tranexamic acid (IV/Oral)
• Factor replacement - specific if available
• Platelet transfusion
• High doses of hormones
– Oral oestro-progestative 50μg
– IV premarin – 40mg IV 4-6 hourly 48 hours with
concomitant use of OC pill.
– High dose Progestagens – e.g. Duphaston 10
mg x 2/day or Norethindrone acetate (Micronovum)
35 mg x1/day
22
MANAGEMENT OF ACUTE BLEEDING
• EUA – evacuation of clots and D&C
• Tamponade the uterus - Foley’s
catheter
• Consider uterotonic - Misoprostol
• Consider rFVIIa
• Uterine artery embolization
Case report in 12 year old with PAI deficiency
Bowkley et al 2007
23
PRISE EN CHARGE DES HEMORRAGIES A
L’ADOLESCENCE
TG négatif
Absence de pathologie
Utérine et de la crase
Discrète
TA, pouls stables
Flux moyen
Hb > 12 g/l
TTT Fer
Calendrier
menstruel
Modérée
TA,pouls stables
Flux important
Hb 10-12 g/l
OCP 35
4x/j 2j,
3x/j 1j
2x/j 1j
1x/j pdt 3-6mois
TTT Fer
Calendrier
menstruel
Sévère
TA, pouls stables
Flux important
Hb < 10 g/l
TTT comme
modérée, si pas
de réponse hosp
Très sévère
Hémodyn. instable
Flux incontrôlable
Hb < 10g/l
Hospitalisation
Iv cristalloïdes
OCP 50
4x/j 2 j, 3x/j 1j etc
Si pas stop saignement,
Oestrogènes conjuguées
IV 25 mg/6h
24
LONG TERM MANAGEMENT
Tranexamic acid
Effective dose 1gm x4/d
DDAVP nasal spray
300µg/day – max 4-5 days
Hematologist OK
Fluid restriction
Combined oral contraceptives
-recurrent ovulation bleeding
-irregular cycles
-dysmenorrhea
-contraception wanted
Combination treatments
High dose Progestagens
GnRH analogues + add back therapy
(e.g. Tibolone 2.5 mg)
25
CONTINIOUS COC
Adolescents prefer less menstruation
American Survey
71% of 321 girls (15-19 years)- > 3 month or never
German study
68% of 310 girls (15-19 years)- once / 3 months or less
Harris Poll 2002, Wiegratz et al 2004
26
LNG IUS : Royal Free Experience
PBAC Score
Hb concentration
9 months
P = < 0.001
P = < 0.001
500
16
14
400
200
100
Successful use in 13/14
girls with intellectual
disability
Jayasinghe et al 2007
12
Hb (g/L)
300
IUS in Adolescents
•Limited experience
•Recent report
10
8
6
4
2
0
0
2 years
27
CONCLUSION
• Adolescents - Significant menstrual
problems
• Bleeding disorders
• A common underlying cause
• Gynaecological bleeding – First presentation
• The challenge – Identification of bleeding
disorders as a cause
• Optimal care
• Multidisciplinary care
• Individualized approach to treatment
28
DYSMENORRHEA IN
ADOLESCENTS
29
CHRONIC PELVIC PAIN (CPP)
ACOG DEFINITION
Noncyclic Pelvic Pain during 3 months
or
Cyclic Pain Pelvic of 6-month duration
interfering with one’s normal activities of daily
living.
Chronic Pelvic Pain: An Integral Approach. APGO Educational Series on Women’s
Health Issues. Washington, DC: Association of Professors of Gynecology and
Obstetrics; 2000.
30
THE INTERNATIONAL ASSOCIATION FOR
THE STUDY OF PAIN DEFINITION
OF CPP
• Pain that has a gynaecologic origin but for
which no definitive lesion or cause is identified
= Primary Dysmenorrhea
Steege J. Chronic Pelvic Pain: Integrated Approach. Philadelphia, PA: WB Saunders; 1997.
• Secondary Dysmenorrhea refers to painful
menses from an identifiable source.
http://www.pelvicpain.org.
31
PREVALENCE
• Dysmenorrhea - most common gynaecological
complaint and leading cause of short-term
school or work absenteeism among female
adolescents and young adults.
• U.S. studies report rates of up to 52% absenteeism
Klein JR & Litt IF. 1981. Epidemiology of adolescent dysmenorrhea. Pediatrics
Anderesch B & Milsom I. 1982. An epidemiologic study of young women with
dysmenorrhea. Am. J. Obstet. Gynecol.
Banikarim C., M.R. et al. 2000. Prevalence and impact of dysmenorrhea on Hispanic
female adolescents. Arch. Pediatr. Adolesc. Med.
32
PREVALENCE
In a Sweedish epidemiologic study :
• 60% to 70% reported painful periods
• 15% interruption of their daily activities
because of menstrual pain
Pelvic abnormalities – endometriosis, uterine
anomalies, in 10% with severe symptoms.
Andresh B, Milsom I. An epidemiological study of young women with
dysmenorrhea. Am J Obstet Gynecol. 1982
33
• Many do not seek medical advice or are undertreated
O’connel K et al. 2006. Selftreatment patterns among
adolescent girls with dysmenorrhea. J. Pediatr. Adolesc. Gynecol.
• 98% use non pharmacologic methods : heat, rest, or
distraction with perceived effectiveness of about 40%
or less.
Campbell MA Clin J Pain 1999
• 30-70% self medication with OTC preparations for
pain.
• 57% sub therapeutic doses
• Only 54% of adolescents knew that certain
medications could relieve menstrual cramps.
Johnson J. 1988. Level of knowledge among adolescent girls regarding
effective treatment for dysmenorrhea. J. Adolesc. Health
Campbell, MA & Mcgrath PJ. 1997. Use of medication by adolescents for
34
the management of menstrual discomfort. Arch. Pediatr. Adolesc. Med.
SYMPTOMS OF DYSMENORRHEA
Cramps
Nausea
Vomiting
Loss of appetite
Headaches
Backaches
Leg aches
Weakness
Dizziness
Diarrhea
Facial blemishes
Abdominal pain
Flushing
Sleeplessness
General aching
Depression
Irritability
Nervousness
35
RISK FACTORS
• Ovulatory cycles, increased duration and
amount of menstrual flow.
Anderesch B & Milsom I. 1982. An epidemiologic study of young women with
dysmenorrhea. Am. J. Obstet. Gynecol.
• Low fish consumption
Balbi C. et al. 2000. Influence of menstrual factors and dietary habits on
Menstrual pain in adolescence age. Eur. J. Obstet Gynecol Reprod. Biol
• Cigarette smoking may increase duration nicotine-induced vasoconstriction.
Hornsby PP. et al. 1998. Cigarette smoking and disturbance of menstrual
function. Epidemiology
36
PATHOPHYSIOLOGY OF 1° DYSMENORRHEA
37
DIFFERENTIAL DIAGNOSIS
Provided a negative pregnancy test
•
•
•
•
•
•
•
•
Pelvic inflammatory disease
Tubo-ovarian abscess
Endometriosis
Muellerian malformations
Adhesions
Ovarian cysts
Ovarian neoplasms
Polyps and fibroids
38
ENDOMETRIOSIS
• Delayed diagnosis
Duration from onset of symptoms until diagnosis of
endometriosis made 7.0 years (range 3.5-12.1)
Arruda MS et al Hum Reprod 2003,18:756-759
• In Australia, in teenagers, 8.8 years between the onset
of symptoms and the diagnosis of endometriosis
(women in 30s = 1.5 years)
Endometriosis Association of Victoria. Survey of
Symptoms of Endometriosis and Delay in Diagnosis 1989
• Referral Centre incidence reported 45% - 70%
Laufer MR et al. Prevalence of endometriosis in adolescent women with
chronic pelvic pain not responding to conventional therapy. J Pediatr
39
Adolesc Gynecol. 1997
ANOMALIES OF THE REPRODUCTIVE TRACT THAT COULD RESULT IN ENDOMETRIOSIS
40
EVALUATION
• History: age at menarche, menstrual pattern,
onset and character of menstrual cramps and
other menstruation-associated symptoms,
response to analgesic medication, sexual
activity, sexual abuse history, contraception,
condom use, history of sexually transmitted
diseases, vaginal discharge, school
performance and school/work absenteeism,
• Family history of menstrual disorders (6.9%
endometriosis in first-degree relatives).
41
EVALUATION
• Psychological history and aspects of
dysmenorrhea, as well as, sequelae of CPP
• If patient never been sexually active –
Pelvic examination is not necessary.
• Pelvic and rectal examinations examination
should be performed in a sexually active
adolescent who develops new-onset or
more severe dysmenorrhea or with a history
suggestive of secondary dysmenorrhea.
42
EVALUATION
• Response to treatment is important
• US
• Consider laparoscopy for a definitive
diagnosis of endometriosis
• Pelvic IRM is indicated if suspicion of
an obstructive pelvic anomaly.
43
TREATMETNT OPTIONS
TRADITIONAL TREATMENT APPROACH
• Nonsteroidal Anti-inflammatory Drugs
(NSAIDs)
• Combined Oral Contraceptives
• Long-acting Hormonal Therapies
• Nontraditional Treatment-Alternatives and
Adjuvant Therapies
44
NONSTEROIDAL ANTI-INFLAMMATORY
DRUGS (NSAIDs)
• IBUBROFEN 200–600 mg every 6 h as needed
• NAPROXEN sodium 440–550 mg initially, followed by
220–275 mg every 8 h as needed
• MEFENACIDE ACID 500 mg initially, followed by
250mg every 6 h as needed
• CELECOXIB (COX-2 Inh) 400 mg initially, followed by
200 mg every 12 h as needed (girls ≥18 years)
45
TREATMETNT OPTIONS
TRADITIONAL TREATMENT APPROACH
• Nonsteroidal Anti-inflammatory Drugs
(NSAIDs)
• Combined Oral Contraceptives
• Long-acting Hormonal Therapies
• Nontraditional Treatment-Alternatives and
Adjuvant Therapies
46
TREATMETNT OPTIONS
TRADITIONAL TREATMENT APPROACH
• Nonsteroidal Anti-inflammatory Drugs
(NSAIDs)
• Combined Oral Contraceptives
• Long-acting Hormonal Therapies
47
NON-TRADITIONAL TREATMENT
ALTERNATIVES AND ADJUVANT THERAPY
48
NON-TRADITIONAL TREATMENT
ALTERNATIVES AND ADJUVANT
THERAPY
• HERBS
• TENS - TRANSCUTANEOUS ELECTRICALNERVE STIMULATOR
• ACUPUNCTURE
49
CONCLUSION
• Dysmenorrhea - most common gynaecological
complaint among adolescent females and is
usually primary, associated with normal
ovulatory cycles and with no pelvic pathology.
• Only 10% of adolescents suffer from secondary
dysmenorrhea resulting from pelvic
abnormalities such as endometriosis or uterine
anomalies.
• Potent prostaglandins and leukotrienes play an
important role in generating the symptoms of
dysmenorrhea.
50
CONCLUSION
• NSAIDs are the most common pharmacologic
treatment for dysmenorrhea.
• Adolescents with symptoms that do not respond
to treatment with NSAIDs x 3 menstrual periods >
Hormonal treatment x 3 menstrual cycles.
• There is some medical evidence demonstrating
that complimentary and alternative medications
may offer a therapeutic adjunct for adolescents
with pelvic pain.
51
CONCLUSION
• Adolescents with dysmenorrhea who do not
respond to this treatment should be evaluated
for secondary causes of dysmenorrhea >
consider imaging + laparoscopy
• The care provider’s role must explain the
pathophysiology of dysmenorrhea, address
any concern that the patient has about her
menstrual period, and review effective
treatment options for dysmenorrhea with the
patient.
52
M E R C I
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