IE3: Menstrual Disorders 2024

What are the menstrual disorders?

• Amenorrhea

• Heavy menstrual bleeding (“menorrhagia”)

• Abnormal Uterine Bleeding with Ovulatory Dysfunction (PCOS)

• Dysmenorrhea

• Premenstrual syndrome & Premenstrual Dysphoric Disorder

  
  

What is amenorrhea?

• No menstrual bleeding in a 90 day period

  • Primary: absence of menses by age 15 in no history of menstruation (rare)

  • Secondary: lack of menses for 3 cycles + in a previous menstruating woman

What does amenorrhea indicate?

• Underlying d/o

  • Anatomical abnormality (pregnancy, uterine issue)

  • Endocrine disturbance and anovulation

  • Ovarian insufficiency/failure

What are signs/sx of amenorrhea?

• Infertility, vaginal dryness, decreased libido

  • Presence of acne, hirsutism, hair loss, acanthosis nigricans (androgen excess)

What do you assess in Amenorrhea?

• Pregnancy test

• Serum FSH & LH

• TSH

• Prolactin

• PCOS suspected:

  • Free and total testosterone

  • Dehydroepiandrosterone

  • Fasting glucose

  • Fasting lipid panel

• Progesterone challenge

• Pelvic ultrasound

  
  

What is the goal of treatment for amenorrhea?

• Bone density preservation, ovulation restoration (fertility)

For treatment of amenorrhea, what issues do we want to prevent as well?

• Prevention of other issues like hypoestrogenism (premature ovarian failure), dyspareunia, lack of secondary sex characteristics, absence of menarche

What are non-pharm treatment of amenorrhea?

• Weight management (i.e. weight gain in cases of anorexia, exercise management)

• Cognitive behavioral therapy

• Avoidance of medications that induce hyperprolactinemia

What is pharm treatment of amenorrhea?

• Hypoestrogenic conditions – estrogen supplementation

  • Preferred: estradiol patch with cyclic oral progestin (reduce osteoporosis risk)

  • Alternatives: Oral contraceptive, conjugated equine estrogen

• Hyperprolactinemia

  • Dopamine agonists (bromo, caber)

• Other

  • Progestins for induction for withdrawal bleed, followed by estrogen/progestin therapy

What is heavy menstrual bleed (HMB) (menorrhagia)?

• Menstrual blood loss greater than 80 mL per cycle or bleeding lasting greater than 7 days per cycle

  • Diagnosis can also be considered based on QOL impact or those with additional symptoms less than at 80 mL loss

What are possible signs of HMB?

• 1 or more tampon or pad per hour for several hours

• Needing more than one pad to control flow

• Needing to change pad or tampon overnight

• Passing clots larger than a quarter

What is the primary goal of HMB treatment?

• Primary goal is to reduce menstrual flow, improve QOL and reduce
  surgical intervention

What are other signs of HMB?

• Orthostasis, tachycardia, pallor (acute blood loss, anemia)

What are nonpharm interventions in HMB?

• Surgical (hysterectomy or endometrial ablation)

What is the pharm treatment for HMB?

• Acute severe bleeding episodes

  • Estrogen, therapy may be continued to prevent future occurrences

• Maintenance

  • CHC or progestin only regimens

  • Estradiol valerate/dienogest combination has FDA approval for HMB management (NATAZIA®- four phasic)

• Hormonal IUD – highly effective, good data on limiting surgical intervention needs

• NSAIDs

  • Administered during menses, no contraceptive benefits but option for those with inability to use hormonal options

• Tranexamic acid (during menses only)

  • Appropriate in those planning pregnancy or who hormone therapy is not appropriate

  • Renal dosing needs, avoid in those with history or high risk for VTE

What is the most common cause of AUB-O? (abnormal uterine bleeding with ovulatory dysfunction)

• PCOS, other causes may be perimenopause (normal transition to menopause)

What is characteristic of AUB-O?

• Irregular, heavy, prolonged uterine bleed

• Perimenopausal sx (hot flash, night sweat, vaginal dryness)

• Acne, hirsutism, obesity (PCOS)

What is nonpharm for AUB-O?

• Weight management, weight loss of 5-10% can improve menstrual regularity, ovulatory function, reduce hirsutism, increase insulin sensitivity, improve response to fertility treatment

• Surgical intervention for those NOT planning to bear childre

What is pharmacologic treatment in AUB-O?

• CHC – cycle regulation (also indicated for hyperandrogenism seen in PCOS), Progestin only regimens are a good option for estrogen intolerance or contraindications. In PCOS, minimal androgenic side effects (norgestimate or desogestrel) or anti androgenic effects (drosperinone) are preferred

• Depot or oral MPA will allow for endometrial suppression

• Hormonal IUD

• Metformin in cases of insulin resistance – also reduces circulating androgens and improve ovulation rates, can be used in combination with CHC