Menstruation disorders

Published on 09/03/2015 by admin

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Chapter 3 Menstruation disorders

Anusch Yazdani, Judith Goh

Terminology for describing menstruation disorders has been under review recently with some authors advocating eradication of the older terms such as ‘menorrhagia’ and ‘dysfunctional uterine bleeding’. As there is currently no consensus on this issue, this chapter will continue to use the previous terminology.

Menorrhagia

Definition. Menorrhagia is a menstrual blood loss greater than 80 mL per cycle (the average menstrual loss is 35 mL per cycle).

Incidence. Menorrhagia occurs in about 10%–20% of women.

Causes of menorrhagia

Dysfunctional uterine bleeding

This is abnormal bleeding (heavy, prolonged or frequent) from the uterus, not due to organic disease/malignancy or pregnancy. It accounts for 50%–60% of cases of menorrhagia. It is subdivided for treatment purposes into:

• anovulatory cycles, which occur at the extremes of menstrual life, in polycystic ovarian syndrome and obesity—due to abnormalities in the hypothalamic–pituitary–ovarian axis
• ovulatory cycles—mainly due to defects in regulation of blood loss/prostaglandin disorders during menstruation

Systemic causes

• hypothyroidism, most likely from anovulation
• coagulation/bleeding disorders such as von Willebrand’s disease, platelet function disorders, and use of anticoagulants (about 2% prevalence of bleeding disorders in the general community, but it affects up to 20% of women with proven menorrhagia and rates are higher in adolescents)

Local/gynaecological causes

• endometriosis/adenomyosis
• chronic pelvic inflammatory disease
• uterine tumours: benign submucosal leiomyoma, endometrial polyps, malignant lesions (hyperplasia, carcinoma)
• ovarian tumours
• intrauterine contraceptive devices, which can double menstrual loss in about 50% of patients

History and investigation of menorrhagia

History

• menstrual history, contraception, thyroid disease, bleeding tendency
• exclusion of pregnancy, cervical pathology
• pictorial chart of menstrual loss, number of pads/tampons used

Investigations

• full blood count, iron studies, thyroid function test
• follicle-stimulating hormone (FSH), luteinising hormone (LH), human chorionic gonadotrophin (hCG)
• platelet function studies for platelet/coagulation disorders (which cause up to 20% of adolescent admissions for menorrhagia)
• cervical cytology
• ultrasound scan of pelvis as a first-line diagnostic tool to exclude structural anomalies
• hysteroscopy and endometrial curettage (especially in women >45 years old with failed treatment)
• tests for ovulation (day 21 serum progesterone)

Medical management of menorrhagia

The general treatment for menorrhagia depends on many factors, including the woman’s choice, contraindications and future fertility needs.

Prostaglandin inhibitors

• mefenamic acid
• naproxen or other non-steroidal anti-inflammatory drugs (can reduce menstrual loss by 20%–50%, which may be improved if used in conjunction with the oral contraceptive pill; also beneficial in women with dysmenorrhoea)

Antifibrinolytics and haemostatics

• tranexamic acid, aminocaproic acid
• ethamsylate, which reduces capillary fragility and inhibits prostaglandin synthesis

Hormonal therapy

Combined oral contraceptive pill

This reduces menstrual blood flow by inhibiting ovulation and decreasing endometrial thickness.

Progesterone

• Routes of administration are oral, intramuscular, intrauterine and subcutaneous implants.
• It may cause irregular bleeding.
• Cyclical oral progesterone therapy:

• This reduces menstrual loss, but is not as effective as transexamic acid or Mirena device (Cochrane review).
• High doses of norethisterone are commonly used to reduce or arrest bleeding in emergency treatment of dysfunctional uterine bleeding.

• Levonorgestrel-releasing intrauterine system has the added advantage of being an effective form of contraception and reducing progesterone systemic side effects. A common side effect is irregular bleeding for the first 6 months.

Surgical management of menorrhagia

Hysteroscopic removal of polyps and fibroids

• Hysteroscopy and curettage is an essential diagnostic tool.
• Endometrial polyps and submucosal fibroids may be removed via the hysteroscope.

Endometrial ablation/resection

• an option for a woman who has completed her childbearing and has dysfunctional bleeding
• endometrial ablation/resection (produces amenorrhoea or an acceptable reduction in blood loss during periods in 90% of patients)
• considered with normal uterus and fibroids less than 3 cm

Hysterectomy

• has the advantage of no risk of menstrual loss following the procedure
• is the option when other treatment options have failed
• possible loss of ovarian function even if ovaries conserved

Uterine artery embolisation

This is an option for a woman who has a large fibroid and wishes uterine conservation.

Dysmenorrhoea

Definition. Dysmenorrhoea means painful menstruation. One-half of all women experience some discomfort during menstruation.

Incidence. In up to 10%–20% of women in their late teens or early 20s, dysmenorrhoea affects their daily activities.

Mechanism. True dysmenorrhoea is related to uterine muscle contraction and cervical dilatation. It usually occurs a few hours before and after the onset of menstruation. The pain is in the hypogastrium, radiating to the inner and front of the thighs. During severe attacks, there is associated sweating, nausea, vomiting and diarrhoea.

Causes

• cervical obstruction due to cervical stenosis
• hormonal imbalance: dysmenorrhoea occurring in ovular cycles; pain resulting from excessive amounts of prostaglandins
• endometriosis, a cause of secondary dysmenorrhoea; ache/pain commences perimenstrually and peaks on day 1–2 of the cycle
• fibroids

Treatment

There is a large quantity of treatments published for the management of dysme-norrhoea, including:

• general health and dietary advice
• medical

• simple oral analgesia
• antispasmodics
• non-steroidal anti-inflammatory drugs (these work best if commenced just before the period)
• oral contraceptive pill and levonorgestrel-releasing intrauterine system control endometrial growth so less prostaglandins released
• vitamin B12

• others: transcutaneous electrical nerve stimulation, acupuncture, fish oil, herbal
• surgical

• laparoscopy used to treat endometriosis
• hysterectomy, but pain may still persist; used in most severe cases as last resort

Premenstrual syndrome

Definition. It is a syndrome of psychological, behavioural and physical symptoms occurring in the premenstrual phase of the menstrual cycle.

Prevalence. It affects over 90% of women in the reproductive age and in about 5% it significantly affects daily activities.

Symptoms

• Symptoms/signs are cyclical and recur in the premenstrual phase. They are present to some degree in each cycle.
• During the follicular phase, the woman is symptom-free.
• Symptoms affect lifestyle.
• Symptoms/signs increase in severity before or during menstruation.
• Effects include cognitive, emotional, physical and sensory modalities.
• Symptoms are varied and include anxiety and depression, behavioural/performance-related changes, breast tenderness/fullness/pain, abdominal fullness/discomfort, increase in appetite, acne, sweats, headache and backache.

Causes

The precise mechanism is unknown. There are a number of suggestions, including:

• progesterone involvement, suggested by onset just prior to menstruation
• abnormal immunological reaction to hormonal changes in the menstrual cycle
• hormonal imbalance between oestrogen and progesterone (low progesterone in luteal phase)
• central opioid abnormality, abnormal hypothalamic–pituitary–adrenal axis
• abnormal aldosterone function (causing sodium and water retention)
• abnormal prostaglandin production
• nutritional deficiency, environmental factors

Management

Numerous treatment regimes have been tried with a significant placebo effect.

General

• Encourage the woman to keep a daily record of symptoms over two or three cycles.
• Provide information on the syndrome, exercise and nutrition.
• Develop stress management skills.

Pharmacological

• vitamin B6, calcium carbonate
• antiprostaglandins, such as mefenamic acid
• hormonal (oral contraceptive pill, oestrogen, danazol)
• selective serotonin reuptake inhibitors

Others

• acupuncture, manipulation, bright-light therapy, relaxation, evening primrose oil, exercise
• hysterectomy, oophorectomy

Further reading

El-Hemaidi I., Gharaibeh A., Shehata H. Menorrhagia and bleeding disorders. Current Opinion in Obstetrics and Gynecology. 2007;19:513-520.

Farage M.A., Osborn T.W., MacLean A.B. Cognitive, sensory and emotional changes associated with the menstrual cycle: a review. Archives of Gynecology and Obstetrics. 2008;278:299-307.

Farquhar C., Brown J. Oral contraceptive pill for heavy menstrual bleeding. Cochrane Database of Systematic Reviews.. 2009. Issue 4. Art. No.: CD000154. DOI: 10.1002/14651858

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