This document discusses various types of menstrual disorders including menorrhagia, amenorrhea, oligomenorrhea, and dysmenorrhea. It defines these conditions and discusses their causes such as fibroids, polyps, endometriosis, thyroid disease, and coagulopathies. The document outlines how to evaluate patients with menstrual disorders including relevant history, lab tests, imaging studies, and procedures. It also reviews medical and surgical treatment options.

1. Menstruation Disorders
Rupali Shah
Medical Student
Cardiff University

2. • What are the 3 phases of the menstrual
cycle?
• When does ovulation occur if you had a:
– 28 day cycle
– 35 day cycle

3. Define the following
• Menorrhagia
• Amenorrhoea
• Oligomenorrhoea
• Dysmenorrhoea

4. Heavy Menstrual Bleeding
• Excessive mestrual
loss
• >80ml lost
• Normal blood loss
35ml

5. Causes of menorraghia
• Local
– Fibroids
– Polyps (uterine & cervical)
– Endometriosis
– Chronic PID
– Cancer
• Systemic
– Thyroid disease
– Coagulopathy (VWD)
– Dysfunctional Uterine Bleeding

6. What would you want to ask
patients?
• Flooding
• Clots (relatively objective measure)
• Dysmenorrhoea before period suggests
anatomical cause
• Also ask about anaemia (breathlessness
etc. as many women present with this)

7. Investigations
• Hb
• Exclude systemic cause (coag, TFTs)
• Exclude organic cause
– transvaginal US (rule our endometrial thickness)
– Hysteroscopy (get biopsy eg for endometrial cause)
• Cervical smear
• Pelvic US (if fibroid/mass suspected)
• Diagnostic laproscopy
• Endometrial biopsy (pipelle)
• TFT if indicated

8. Treatmeant
• Medical
– Antifibrinolytics (Plasmin inhibitors)-
tranexamic acid
– NSAIDs-mefanamic acid (contraindicated in
asthma and duodenal ulcers)
– GnRH agonists  amenorrhea (for temporary
use due to severe side effects).
– Progesterone impregnated IUD (Mirena)
– Contraception(COC, contraindicated when at
risk of clotting)

9. Surgical Treatment
• Only when medical therapy has not
worked
• Hysteroscopic
– Endometrial resection / ablation. Heat and laser therapy
ablation. Very successful technique with 40% of women
having complete amenorrheoa and 40% having
reduction in menstrual bleeding.
• Hysterectomy

10. Secondary Amenorrhoea
• Cessation of menses >6 months in a
woman who has previously menstruated
• Can be physiological or pathalogical

11. Physiological
Amenorrhoea
• Pregnancy
• Puerperium
(after child birth)
• Lactation
• The menopause
Pathological
Amenorrhoea
• Hypothalamic
• Pituitary
• Ovarian

12. Amenorhoea causes
• Hypothalamic-Pituitary Ovarian Axis Dysfunction
– Polycystic ovarian syndrome
– Premature ovarian failure(Radiation, Chemotherapy,
Autoimmunity)
– Pituitary – prolactinoma, antipsychotic drugs, Sheehan’s.
– Hypothalamic- Anorexia, stress, Kallman’s.
• Thyroid dysfunction
• Non-classical congenital adrenal hyperplasia
• Outflow Obstruction – Asherman’s syndrome, cervical
stenosis
• Turners syndrome, Mullerian agenesis and imperforate
hymen, are causes of primary amenorrhoea. This is
defined as failure to menstruate by the age of 16.

13. Dysmenorrhoea
– Painful periods
– Associated with high prostaglandin
levels
– Due to contraction and uterine
ischaemia
Primary Dysmenorrhoea
•No organic cause detected
•Responds to NSAIDs
Secondary Dysmenorrhoea
• Pain due to pelvic pathology
•Relieved by onset of menstruation
•Causes include fibroids,
adenomyosis, endometriosis PID,
ovarian tumours

14. Post Coital Bleeding
• Vaginal bleeding following intercourse that is
not menstrual loss
• Cervix is more likely to bleed after trauma if it
isn’t covered by healthy squamous epithelium
• Causes:
– Cervical carcinoma
– Cervical ectropion
– Cervical polyps
– Cervicitis, vaginitis

15. Management of post coital bleeding
• inspect
• Take smear
• Colposcopy may be used to rule out
malignant cause

16. Intermenstrual bleeding
• May coexist with menorrhagia
• More common at extremes of age
• Causes are anovulatory cycles and pelvic
pathology

17. Causes of intermenstrual bleeding
• Anovulatory cycle
– More common in early
and late replroductive
years
• Pelvic pathology
– Non malignant
• Fibroids
• Polyps
(uterine/cervical)
• Adenomyosis
• Ovarian cycts
• Chronic pelvic infection
– Malignant
• Ovarian
• Cervical

18. Things you would want to know and
investigate
• Hb (amount lost)
• US (mainly in women >35 yo and in
younger women who haven’t responded to
medication)
• Endometrial biopsy (when endometrium is
thick)

19. Management of intermenstrual
bleeding
• Drugs
– No anatomical cause detected
– COC
– Progestogens (high dose  amenorrhoea)
• Surgery
– Polyp can be removed  histology

20. Things I haven’t covered today, but
will cover in other presentations
• Pre-menstrual syndrome
• Post-menopausal bleeding
• Oligomenorrhoea