1

Menorrhagia is defined quantitatively as a loss of >80 cc of blood per cycle, based on blood loss required to produce iron-deficiency anemia. A complaint of heavy menses is subjective and has a poor correlation with excessive blood loss. Predictors of menorrhagia include bleeding resulting in iron-deficiency anemia or a need for blood transfusion, excessive pad or tampon use, menses lasting longer than 8 days, passage of clots, bleeding through protection, or flooding at night. Menorrhagia is a common symptom in women with underlying bleeding disorders and is reported in the majority of women with vWD and factor XI deficiency and in symptomatic carriers of hemophilia A. Women with underlying bleeding disorders are more likely to have other bleeding symptoms, including bleeding after dental extractions, postoperative bleeding, and postpartum bleeding, and are much more likely to have menorrhagia beginning at menarche than women with menorrhagia due to other causes.

Menorrhagia From Wikipedia, the free encyclopedia Menorrhagia

ICD-10 ICD-9

N92.0 Premenopausal menorrhagia627.0

DiseasesDB 22575 eMedicine med/1449 MeSH D008595

Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. Menorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods, or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhea).

Contents [hide]

1 Definition 2 Cause o 2.1 Disorders of coagulation o 2.2 Excessive build up in endometrial lining o 2.3 Consideration by nature of the menstrual cycle o 2.4 Differential Diagnosis o 2.5 Risk Factors o 2.6 ICD-9 codes 3 Diagnosis 4 Treatment o 4.1 Medications o 4.2 Surgery 5 Complications 6 References 7 Footnotes [edit]Definition A normal menstrual cycle is 2535 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. A blood loss of greater than 80 ml or lasting longer than 7 days constitutes menorrhagia (also called hypermenorrhea). Some authors use menorrhagia exclusively when describing excessive quantity and hypermenorrhea for prolonged duration (although most use both terms interchangeably in the clinical setting). In practice

this is not usually directly measured by patients or doctors. Menorrhagia also occurs at predictable and normal (usually about 28 days) intervals, distinguishing it from menometrorrhagia, which occurs at irregular and more frequent intervals. It is possible to estimate the amount of bleeding by the number of tampons or pads a woman uses during her period. As a guide a regular tampon fully soaked will hold about 5ml of blood. One may also have lighter cycles in volume, but blood flow may continue more than seven days thus constituting menorrhagia. An OB/GYN should still be consulted. [edit]Cause Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. Most common cause include blood disorder or stress-related disorders. A brief overview of causes is given below, followed by a more formal medical list based on the nature of the menstrual cycle experienced. [edit]Disorders of coagulation With the shedding of an endometrial lining's blood vessels, normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such asITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies pfa col/epi can also be used to ascertain platelet function abnormalities [edit]Excessive build up in endometrial lining

Periods soon after the onset of menstruation in girls (the menarche) and just before menopause may in some women be particularly heavy. Hormonal disorders involving the ovaries-pituitary-hypothalamus (the 'ovarian endocrine axis') account for many cases, and hormonal-based treatments may regulate effectively. The lining of the uterus builds up naturally under the hormonal effects of pregnancy, and an early spontaneous miscarriage may be mistaken for a heavier than normal period. As women age and move towards menopause, ovulation is delayed and the remaining follicles in the ovaries become resistant to GnRH (Gonadotropin releasing hormone) secreted by the hypothalamus gland in the brain. Either that or they don't develop an egg, and thus no progesterone is produced. Without progesterone, the estrogen is "unopposed" and keeps building up the lining of the uterus. During a woman's period, the endometrial lining which is normally shed never gets the signal to stop thickening. It keeps growing and sheds irregularly. Due to the extra thickness, the bleeding is unusually heavy. Less frequently in this age group, too little estrogen causes the irregular bleeding. Most cases of hemorrhagic are due to normal hormonal changes preceding menopause. Irritation of the endometrium may result in increased blood flow, e.g. from infection (acute or chronic pelvic inflammatory disease) or the contraceptive intrauterine device (note the distinction from the IntraUterine System which is used to treat this condition).

Fibroids in the wall of the uterus sometimes can cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrium's surface area. Abnormalities of the endometrium such as adenomyosis (so called "internal endometriosis") where there is extension into the wall of the uterus gives rise to an enlarged tender uterus. Note, true endometriosis is a cause of pain (dysmenorrhoea) but usually not alteration in menstrual blood loss. Endometrial carcinoma (cancer of the uterine lining) usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia. Bleeding in between periods (intermenstrual bleeding or IMB) or after the menopause (post-menopausal bleeding or PMB) should always be considered suspicious. [edit]Consideration by nature of the menstrual cycle

Excessive menses but normal cycle: Painless: Fibroids ( leiomyoma ) Ovarian endocrine disorder (dysfunctional uterine bleeding or DUB)(the most common cause) Coagulation defects (rare) endometrial carcinoma endometrial polyp Painful: Pelvic inflammatory disease Endometriosis adenomyosis

Short cycle (<21 days) but normal menses (epimenorrhoea or polymenorrhoea). These are always anovulatory cycles due to hormonal disorders. Short cycle and excessive menses (epimenorrhagia) due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours. Excessive menses and long intervals. Anovular ovarian disorder due to prolonged estrogen production. This may occur following prolonged continuous courses of the combined oral contraceptive pill (e.g. where several packets are taken without a withdrawal gap in order to defer menstruation). [edit]Differential Diagnosis

Pregnancy complications: Ectopic pregnancy Incomplete abortion Miscarriage Threatened abortion Nonuterine bleeding: Cervical ectropion/erosion Cervical neoplasia/polyp Cervical or vaginal trauma Condylomata Atrophic vaginitis Foreign bodies Pelvic inflammatory disease (PID): Endometritis

Tuberculosis Hypothyroidism [edit]Risk Factors

Obesity Anovulation Estrogen administration (without progestogens) Prior treatment with progestational agents or oral contraceptives increases the risk of endometrial atrophy, but decreases the risk of endometrial hyperplasia or neoplasia [edit]ICD-9 codes

Classification of some causes Cause Polyp of corpus uteri Endometrial cystic hyperplasia Other specified disorders of uterus, NEC Excessive or frequent menstruation Puberty bleeding Irregular menstrual cycle ICD-9 code 621.0 621.3 621.8 626.2 626.3 626.4

Metrorrhagia Disorders of menstruation and other abnormal bleeding from female genital tract, other Premenopausal menorrhagia Postmenopausal bleeding [edit]Diagnosis

626.6

626.8

627.0 627.1

Pelvic and rectal examination Pap smear Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.[1] Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia Hysteroscopy [edit]Treatment

Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods). If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause. If anemia occurs then iron tablets may be used to help restore normal hemoglobin levels.

10

The condition is often treated with hormones, particularly as dysfunctional uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought. Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used. Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required. Tranexamic acid tablets that may reduce loss by up to 50%.[citation needed] BMJ. 1996 Sep 7;313(7057):579-82. Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. Bonnar J, Sheppard BL. SourceTrinity College, Department of Obstetrics and Gynaecology, St. James Hospital, Dublin, Ireland. This may be combined with hormonal medication previously mentioned. Anti-inflammatory medication like NSAIDs may also been used, but typically cause only a 30%[citation needed] reduction in flow. A definitive treatment for menorrhagia is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to reduce the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids

11

may be dealt with by local removal (myomectomy). A further surgical technique isendometrial ablation (destruction) by the use of applied heat (thermoablation). In the UK the use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003[2]. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS[3][4] which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery[5]. [edit]Medications These have been ranked by the UK's National Institute for Health and Clinical Excellence:[1] First line IntraUterine System insertion Second Line Tranexamic acid an antifibrinolytic agent Non-steroidal anti-inflammatory drugs (NSAIDs) Combined oral contraceptive pills to prevent proliferation of the endometrium Third line Oral progestogen (e.g. norethisterone), to prevent proliferation of the endometrium Injected progestogen (e.g. Depo provera) Other options Gonadotrophin-releasing hormone (GnRH) agonists (e.g. Goserelin) [edit]Surgery

12

Dilation and curettage (D&C) is no longer performed for cases of simple menorrhagia, having a reserved role if a spontaneous abortion is incomplete Endometrial ablation Uterine artery embolisation (UAE) Hysteroscopic myomectomy to remove fibroids over 3 cm in diameter [edit]Complications

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia. Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration. [edit]References

Continuous Identification of Research Evidence (collaborative of the WHO, and US CDC & Johns Hopkins Hospital) - Search of Evidence about the IUS Abnormal vaginal bleeding National Guideline Clearinghouse Menorrhagia - Menstrual Abnormalities and Abnormal Uterine Bleeding Menstrual Abnormalities and Abnormal Uterine Bleeding - Armenian Medical Network

13

Abnormal uterine bleeding/dysfunctional uterine bleeding. Intracorp - Public For Profit Organization. 2005. Various pagings. NGC:004390 Working group on inherited bleeding disorders rbdd - Rare Bleeding Disorders database Project Red Flag Information About Women and Bleeding Disorders [6] Adenomyosis Information from MayoClinic.com Working group on menorrhagia Menorrhagia and other gynaecological problems in women affected by bleeding disorders [edit]Footnotes

1. ^ a "CG44 Heavy menstrual bleeding: Understanding NICE guidance" (PDF). National Institute for Health and Clinical Excellence (UK). 24 January 2007. 2. ^ Reid P, Mukri F (Apr 23 2005). "Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 20023".BMJ 330 (7497): 938 9. doi:10.1136/bmj.38376.505382.AE. PMC 556338. PM ID 15695496. 3. ^ Hurskainen R, Teperi J, Rissanen P, Aalto A, Grenman S, Kivel A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J (Mar 24 2004). "Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up". JAMA 291 (12): 1456 63.doi:10.1001/jama.291.12.1456. PMID 15039412.

14

4. ^ Istre O, Trolle B (August 2001). "Treatment of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection". Fertil Steril 76 (2): 304 9.doi:10.1016/S0015-0282(01)019094. PMID 11476777. 5. ^ Stewart A, Cummins C, Gold L, Jordan R, Phillips W (January 2001). "The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review". BJOG 108 (1): 74 86. doi:10.1016/S0306-5456(00)000206. PMID 11213008. 6. ^ Feig, Robert L. and Nicole C. Johnson.. First Aid for the Obstetrics and Gynecology Clerkship. ISBN ISBN 007-136423-4. Background Menorrhagia is defined as menstruation at regular cycle intervals but with excessive flow and duration and is one of the most common gynecologic complaints in contemporary gynecology. Clinically, menorrhagia is defined as total blood loss exceeding 80 mL per cycle or menses lasting longer than 7 days.[1] The World Health Organization reports that 18 million women aged 30-55 years perceive their menstrual bleeding to be exorbitant.[2] Reports show that only 10% of these women experience blood loss severe enough to cause anemia or be clinically defined as menorrhagia.[1, 3, 4] In practice, measuring menstrual blood loss is difficult. Thus, the diagnosis is usually based upon the patient's history.

15

A normal menstrual cycle is 21-35 days in duration, with bleeding lasting an average of 7 days and flow measuring 25-80 mL.[5] Menorrhagia must be distinguished clinically from other common gynecologic diagnoses. These include metrorrhagia (flow at irregular intervals), menometrorrhagia (frequent, excessive flow), polymenorrhea (bleeding at intervals < 21 d), and dysfunctional uterine bleeding (abnormal uterine bleeding without any obvious structural or systemic abnormality).[5] Nearly 30% of all hysterectomies performed in the United States are performed to alleviate heavy menstrual bleeding.[6] Historically, definitive surgical correction has been the mainstay of treatment for menorrhagia. Modern gynecology has trended toward conservative therapy both for controlling costs and the desire of many women to preserve their uterus. Heavy menstrual bleeding is a subjective finding, making the exact problem definition difficult. Treatment regimens must address the specific facet of the menstrual cycle the patient perceives to be abnormal, (ie, cycle length, quantity of bleeding). Finally, treatment success is usually evaluated subjectively by each patient, making positive outcome measurement difficult. Pathophysiology Knowledge of normal menstrual function is imperative in understanding the etiologies of menorrhagia. Four phases

16

constitute the menstrual cycle, follicular, luteal, implantation, and menstrual. In response to gonadotropin-releasing hormone (GnRH) from the hypothalamus, the pituitary gland synthesizes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which induce the ovaries to produce estrogen and progesterone. During the follicular phase, estrogen stimulation results in an increase in endometrial thickness. This also is known as the proliferative phase. The luteal phase is intricately involved in the process of ovulation. During this phase, also known as the secretory phase, progesterone causes endometrial maturation. If fertilization occurs, the implantation phase is maintained. Without fertilization, estrogen and progesterone withdrawal results in menstruation. Etiologic causes are numerous and often unknown. Factors contributing to menorrhagia can be sorted into several categories, including organic, endocrinologic, anatomic, and iatrogenic. If the bleeding workup does not provide any clues to the etiology of the menorrhagia, a patient often is given the diagnosis of dysfunctional uterine bleeding (DUB). Most cases of DUB are secondary to anovulation. Without ovulation, the corpus luteum fails to form, resulting in no progesterone secretion. Unopposed estrogen allows the endometrium to proliferate and thicken. The endometrium

17

finally outgrows its blood supply and degenerates. The end result is asynchronous breakdown of the endometrial lining at different levels. This also is why anovulatory bleeding is heavier than normal menstrual flow. Hemostasis of the endometrium is directly related to the functions of platelets and fibrin. Deficiencies in either of these components results in menorrhagia for patients with von Willebrand disease or thrombocytopenia. Thrombi are seen in the functional layers but are limited to the shedding surface of the tissue. These thrombi are known as "plugs" because blood can only partially flow past them. Fibrinolysis limits the fibrin deposits in the unshed layer. Following thrombin plug formation, vasoconstriction occurs and contributes to hemostasis. Anatomic defects or growths within the uterus can alter either of the aforementioned pathways (endocrinologic/hemostatic), causing significant uterine bleeding. The clinical presentation is dependent on the location and size of the gynecologic lesion. Organic diseases also contribute to menorrhagia in the female patient. For example, in patients with renal failure, gonadal resistance to hormones and hypothalamic-pituitary axis disturbances result in menstrual irregularities. Most women in this renal state are amenorrheic, but others also develop menorrhagia. If uremic coagulopathy ensues, it usually is due to platelet dysfunction and abnormal factor VIII function. The resulting prolonged bleeding time causes menorrhagia that can be very tenuous to treat.

18

Due to the overwhelming factors that can contribute to the dysfunction of either the endocrine or hematological pathways, in-depth knowledge of an existing organic disease is just as imperative as understanding the menstrual cycle itself. Epidemiology Frequency United States While menorrhagia remains a leading reason for gynecologic office visits, only 10-20% of all menstruating women experience blood loss severe enough to be defined clinically as menorrhagia.[4] Mortality/Morbidity Infrequent episodes of menorrhagia usually do not carry severe risks to women's general health.

Patients who lose more than 80 mL of blood, especially repetitively, are at risk for serious medical sequelae. These women are likely to develop iron-deficiency anemia as a result of their blood loss. Menorrhagia is the most common cause of anemia in premenopausal women. This usually can be remedied by simple ingestion of ferrous sulfate to replace iron stores. If the bleeding is severe enough to cause volume depletion, patients may experience shortness of breath, fatigue, palpitations, and other related symptoms. This level of anemia necessitates hospitalization for intravenous fluids and possible transfusion and/or intravenous estrogen therapy. Patients who do not respond

19

to medical therapy may require surgical intervention to control the menorrhagia. Other sequelae associated with menorrhagia usually are related to the etiology. For example, with hypothyroidism, patients may experience symptoms associated with a lowfunctioning thyroid (eg, cold intolerance, hair loss, dry skin, weight gain) in addition to the effects of significant blood loss.[7] Sex Only females are affected by menorrhagia. Age Any woman of reproductive age who is menstruating may develop menorrhagia. Most patients with menorrhagia are older than 30 years.[5] This is because the most common cause of heavy menses in the younger population is anovulatory cycles, in which bleeding does not occur at regular intervals.[8]

History Symptoms related by a patient with menorrhagia often can be more revealing than laboratory tests. Considering the lengthy list of possible etiologies that contribute to menorrhagia, taking a detailed patient history is imperative. Inquiries should include the following:

Exclusion of pregnancy o This is the most common cause of irregular bleeding in women of reproductive age.

20

Pregnancy should be the first diagnosis to be excluded before further testing or medications are instituted. Quantity and quality of bleeding o Quantity is a very subjective issue when considering vaginal bleeding. Best estimates usually are the only source clinicians have available to consider. Helpful references for totaling blood loss may include that the average tampon holds 5 mL and the average pad holds 515 mL of blood. Asking the patient what type of pad (liner vs overnight) was used and if it was soaked may add some insight into what the patient believes to be heavy bleeding. o Quality of bleeding involves the presence of clots and their size. Age o Young patients, from menarche to the late-teen years, most commonly have anovulatory bleeding due to the immaturity of their hypothalamic-pituitary axis. If bleeding does not respond to usual therapy in this age group, a bleeding disorder must be considered. o Women aged 30-50 years may have organic or structural abnormalities. Fibroids or polyps are frequent anatomical findings. Organic causes can be anything from thyroid dysfunction to renal failure. o Postmenopausal women with any uterine bleeding should receive an immediate workup for endometrial cancer. o Endometrial hyperplasia must be considered in women who are obese, aged 70 or older, nulliparous, or have diabetes. Pelvic pain and pathology
o

21

Knowing if a patient has any long-standing diagnosis or known pathology (eg, fibroids) is helpful. o Records from other physicians or hospitalizations may prevent redundancy in ordering lab work or diagnostic imaging. Menses pattern from menarche o If a young patient has had irregular menses since menarche, the most common etiology of her bleeding is anovulation. o Anovulatory bleeding is most common in young girls (aged 12-18 y) and common in obese females of any reproductive age. o If a patient's bleeding normally occurs at regular intervals and the irregularity is new in onset, pathology must be ruled out, regardless of age. Sexual activity o Simple vaginitis (eg, candidal, bacterial vaginosis) may cause intermenstrual bleeding, while gonorrhea and chlamydia may present with heavier bleeding attributed primarily to the copious discharge mixed with the blood. o Chlamydia is a common cause of postpartum endometritis, leading to vaginal bleeding in the weeks following a delivery. o A postpartum infection (eg, endometritis) also may be due to organisms unrelated to sexual activity. Contraceptive use (intrauterine device or hormones) o Commonly, an intrauterine device (IUD) causes increased uterine cramping and menstrual flow. o If a patient has recently discontinued birth control pills, she may return to her "natural" menses and report an increase
o

22

in flow. This actually is normal because most oral birth control pills decrease the flow and duration of a woman's menses. Presence of hirsutism (polycystic ovarian syndrome) o These patients commonly are obese and in an anovulatory state. When they do have a period, it may be very heavy and cause concern for the patient. o The etiology of this is explained in the Introduction to this article. Galactorrhea (pituitary tumor): Any patient complaining of a milky discharge from either breast (while not pregnant, postpartum, or breastfeeding) needs a prolactin level to rule out a pituitary tumor. Systemic illnesses (hepatic/renal failure or diabetes) o As explained in the Introduction, organic diseases may affect either the hormonal or hematologic pathways that are involved in the manifestation of menorrhagia. o If either the hypothalamic-pituitary axis or the coagulation paths are disrupted, heavy bleeding may result. Symptoms of thyroid dysfunction: The alteration of the hypothalamic-pituitary axis may create either amenorrhea (hyperthyroidism) or menorrhagia (hypothyroidism). Excessive bruising or known bleeding disorders o This is especially important in a young patient who does not stop bleeding during her first menses. o This is a very common presentation for an undiagnosed bleeding disorder (von Willebrand disease) in a young girl. Current medications (hormones or anticoagulants) o Any medication that prolongs bleeding time may cause menorrhagia.

23

A patient treated with any progestin therapy may have a withdrawal bleed after cessation of the medication. This bleeding often is heavy and worrisome to patients if they are not forewarned. Previous medical or surgical procedures/diagnoses: This also is helpful in preventing duplication of testing. Physical
o

The physical examination should be tailored to the differential diagnoses formulated by the results of the patient's history. Initial inspection should include evaluation for the following: o Signs of severe volume depletion (eg, anemia): This may help confirm the patient's history of very heavy bleeding and/or prompt immediate inpatient care. o Obesity: This is an independent risk factor for endometrial cancer. Adipose tissue is a locale for estrogen conversion. Therefore, the larger the patient, the more increased the risk (and the higher the unopposed estrogen level on the endometrium). o Signs of androgen excess (eg, hirsutism): This usually points to polycystic ovarian syndrome (PCOS), leading to anovulatory bleeding (see Presence of hirsutism). o Ecchymosis: This usually is a sign of trauma or a bleeding disorder. o Purpura: This also is a sign of trauma or a possible bleeding disorder. o Pronounced acne: This is a sign of PCOS. General examination should include evaluation of the following:

24

Visual fields o Bleeding gums o Thyroid evaluation o Galactorrhea o Enlarged liver or spleen Pelvic examination should evaluate for the presence of external genital lesions. Vaginal/cervical discharge: Look for a copious discharge indicating infection, and confirm the actual site of the bleeding (if present). Assess as follows: o Uterine size, shape, and contour: An enlarged irregularly shaped uterus suggests fibroids if the patient is aged 3050 years. An enlarged uniformly shaped uterus in a postmenopausal patient with bleeding suggests endometrial cancer until proven otherwise. o Cervical motion tenderness: This is a common symptom of pelvic inflammatory disease (PID) that usually is caused by gonorrhea or chlamydia. This is an important diagnosis to exclude, especially in young nulliparous women, because it can lead to pelvic adhesions and infertility. o Adnexal tenderness or masses: This is especially concerning in patients older than 40 years. Ovarian cancer may present with intermenstrual bleeding as its only symptom. Rare but deadly ovarian tumors also can present in teenage girls. Any suspicion of an adnexal mass should prompt an immediate pelvic ultrasound. Causes
o

Etiologies of menorrhagia are divided into 4 categories, organic, endocrinologic, anatomic, and iatrogenic.

25

Organic causes of menorrhagia include infection, bleeding disorders, and organ dysfunction. o Infections can be of any genitourinary origin. The aforementioned sexually transmitted diseases are of greater concern in the teenage and early adult population. Bleeding from the urethra or rectum always must be considered in the workup, especially in the postmenopausal woman who has negative findings after a workup for vaginal bleeding. o Coagulation disorders can evade diagnosis until menarche, when heavy menstrual bleeding presents as an unrelenting disorder. These include von Willebrand disease; factor II, V, VII, and IX deficiencies; prothrombin deficiency; idiopathic thrombocytopenia purpura (ITP); and thromboasthenia.[9] See more on bleeding disorders below. o Organ dysfunction causing menorrhagia includes hepatic or renal failure. Chronic liver disease impairs production of clotting factors and reduces hormone metabolism (eg, estrogen). Either of these problems may lead to heavy uterine bleeding. Endocrine causes of menorrhagia include thyroid and adrenal gland dysfunction, pituitary tumors, anovulatory cycles, PCOS, obesity, and vasculature imbalance. o Both hypothyroidism and hyperthyroidism result in menorrhagia. Even subclinical cases of hypothyroidism produce heavy uterine bleeding in 20% of patients. Menorrhagia usually resolves with correction of the thyroid disorder.[7] o Prolactin-producing pituitary tumors cause menorrhagia by disrupting (GnRH) secretion. This leads to decreased LH

26

and FSH levels, which ultimately cause hypogonadism. Interim stages of menorrhagia result until hypogonadism manifests. o The most common etiology of heavy uterine bleeding is anovulatory cycles. The finding of menorrhagia at irregular intervals without any known organic etiology confirms the clinical diagnosis. This is most common in adolescent and perimenopausal populations. o The hallmarks of PCOS are anovulation, irregular menses, obesity, and hirsutism. Insulin resistance is common and increases androgen production by the ovaries. o Hyperinsulinemia is a direct consequence of obesity. This overproduction of insulin leads to ovarian production of androgens, as occurs in PCOS. o Vasculature imbalance is theorized to be the result of a discrepancy between the vasoconstricting and aggregating actions of prostaglandin F2 (alpha) and thromboxane A2 and the vasodilating actions of prostaglandin E2 and prostacyclin on the myometrial and endometrial vasculature. Anatomic etiologies for menorrhagia include uterine fibroids, endometrial polyps, endometrial hyperplasia, and pregnancy. o Fibroids and polyps are benign structures that distort the uterine wall and/or endometrium. Either may be located within the uterine lining, but fibroids may occur almost anywhere on the uterus. o The mechanism by which endometrial polyps or fibroids cause menorrhagia is not well understood. The blood supply to the fibroid or polyp is different compared to the

27

surrounding endometrium and is thought to function independently. This blood supply is greater than the endometrial supply and may have impeded venous return, causing pooling in the areas of the fibroid. Heavy pooling is thought to weaken the endometrium in that area, and break-through bleeding ensues. Fibroids located within the uterine wall may inhibit muscle contracture, thereby preventing normal uterine attempts at hemostasis. This also is why intramural fibroids may cause a significant amount of pain and cramping. Fibroids may enlarge to the point that they outgrow their blood supply and undergo necrosis. This also causes a great deal of pain for patients. Endometrial hyperplasia usually results from unopposed estrogen production, regardless of the etiology. Endometrial hyperplasia can lead to endometrial cancer in 1-2% of patients with anovulatory bleeding, but it is a diagnosis of exclusion in postmenopausal bleeding (average age at menopause is 51 y). If a woman takes unopposed estrogen (without progesterone), her relative risk of endometrial cancer is 2.8 compared to nonusers.[10] Iatrogenic causes of menorrhagia include IUDs, steroid hormones, chemotherapy agents, and medications (eg, anticoagulants). IUDs can cause increased menstrual bleeding and cramping due to local irritation effects. Steroid hormones and chemotherapy agents disrupt the normal menstrual cycle, which is restored easily upon cessation of the products.

28
o

Anticoagulants decrease clotting factors needed to cease any normal blood flow, including menses. This type of menorrhagia also is easily reversible. Bleeding disorders An international expert panel including obstetrician/gynecologists and hematologists has issued guidelines to assist physicians in better recognizing bleeding disorders, such as von Willebrand disease, as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder.[11] Historically, a lack of awareness of underlying bleeding disorders has led to underdiagnosis in women with abnormal reproductive tract bleeding. The panel provided expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. An underlying bleeding disorder should be considered when a patient has any of the following:

Menorrhagia since menarche Family history of bleeding disorders Adnexal Tumors The normal functioning ovary produces a follicular cyst 6-7 times each year. In most cases, these functional cysts are self-limiting and resolve within the duration of a normal menstrual cycle. In rare situations, a cyst persists longer or becomes enlarged. At this point, it represents a pathological adnexal mass.

Adnexal masses present a diagnostic dilemma; the differential diagnosis is extensive, and most masses are benign.[1, 2, 3] However, without histopathologic tissue

29

diagnosis, a definitive diagnosis is generally precluded. Physicians must evaluate the likelihood of a concerning pathologic process using clinical and radiologic information and balance the risk of surgical intervention for a benign versus malignant process. Since ovaries produce physiologic cysts in menstruating women, the likelihood of a benign process is higher in women of reproductive age. In contrast, the presence of an adnexal mass in prepubertal girls and postmenopausal women heightens the risk of a malignant neoplastic etiology. Elective Abortion Surgical termination The development of accurate over-the-counter pregnancy tests allows for the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in this very early time frame have been termed menstrual extractions, a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed extremely early suction evacuations without histologic tissue confirmation, allowing for maximum confidentiality for both patient and provider. Abortions performed prior to 9 weeks from the last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation. The following methods are available for surgical abortion:

30

Manual vacuum aspiration (menstrual extraction) is used at 4-10 weeks' gestation and is 99.2% effective. Suction curettage is used at 6-14 weeks' gestation. Sharp curettage is used at 4-14 weeks' gestation but is not currently used because of increased blood loss and retained product of conception (POC) compared with suction. Dilation and extraction (D&E) is used at 14-24 weeks' gestation. Intact dilation and extraction (D&X) is used at more than 18 weeks' gestation, but is not performed in the US without prior feticide treatments due to current laws. Hysterotomy is used at 12-24 weeks of gestation and is reserved for the rare instances in which all other methods of abortion have failed or are contraindicated. Hysterectomy is reserved for rare instances in which other gynecological pathology dictates removal of the uterus. Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 88% of abortions are performed at 13 weeks' gestation or less, 97% of abortions were performed using surgical methods in the early days of medical abortions, and now some centers are reporting more than 50% of first trimester procedures by medical abortion protocols.

In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. D&E is considered the safest form of abortion in the second trimester. In contrast, D&X is reputed to pose a greater health risk to the mother

31

(increased risk of cervical incompetence, uterine rupture, abruption, amniotic fluid embolism, and uterine trauma) when compared with that of D&E. However, little published data exist regarding the frequency or complication rates for D&X since it has been a relatively ill-defined procedure until recently. A retrospective study has shown comparable complication rates and obstetric outcomes between these 2 procedures when performed by experienced physicians. Labor induction methods have increasing morbidity/mortality as compared with that of D&E. Hysterectomy/hysterotomy procedures have the highest risk of complications but may still have a role in very rare clinical situations (eg, stenotic cervical os, placenta accreta, leiomyoma obstructing cervical os). The Society of Family Planning released second trimester induction guidelines in February of 2011.[5] Women with a history of prior cesarean delivery are at particularly increased risk of morbidity/mortality when undergoing labor induction as a form of surgical abortion. Labor induction resulted in a 20-fold increased odds ratio of uterine rupture and 2-fold increased risk of blood transfusion in women with a history of prior cesarean delivery as compared with those without a uterine scar. Thus, women with a history of a prior cesarean delivery should undergo either D&E or D&X as the method of surgical abortion. Medical termination Medical abortion is a term applied to a medication-induced elective abortion. This can be accomplished with a variety of medications administered either singly or in succession.

32

Medical abortion has a success rate that ranges from 7595%, with approximately 2-4% of failed abortions requiring surgical abortion and approximately 5-10% of incomplete abortions, depending on the stage of gestation and the medical products used. For a review of multiple studies, see Kahn et al.[6]Patients who select a medical abortion express a slightly greater satisfaction with their route of abortion and, in most cases, express a wish to choose this method again should they have another abortion. Research continues to be performed to more clearly establish which protocol is best, which medications are preferable, and how successfully women and adolescents can diagnose a complete versus an incomplete abortion. Although a critical shortage of providers exists who can provide surgical abortions, in a recent study by Koenig et al, providers who do not perform surgical abortions have indicated a willingness to provide medical abortions.[7] Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Some patients require an emergency surgical abortion, and, for safety concerns, patients undergoing medical abortions need access to providers willing to perform an elective termination. In September of 2000, the FDA approved mifepristone (RU486) for use in a specific medical regimen that includes misoprostol administration for those who do not abort with mifepristone alone. Methotrexate and misoprostol are drugs approved for other indications that can also be used for

33

medical termination of pregnancy. Additional research will determine exactly which regimen is ideal for medical abortions. Medical abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed, the standard has been that the patient must be seen for evaluation of the completeness of the process. Many providers have also routinely used ultrasonography to assess abortion outcome. However, a recent study showed that using a low-sensitivity pregnancy test and clinical examination is sufficient for completeness assessment.[8] The medical regimens initiate the process with progesterone receptor blockage by mifepristone without activating the receptor. This leads to a progesterone effect withdrawal from the decidua with ensuing necrosis and eventual detachment of the placenta at its implantation site. Following this with a prostaglandin, usually misoprostol, then leads to uterine activity and expulsion of the products of conception. It works best up to day 49 of pregnancy and regimens up to day 63 are effective as well. A rare and serious infection of Clostridium sordellii is related to medical abortions. Four deaths associated with this infection have been reported since 2001. Fatal infections are rare, occurring in fewer than 1 in 100,000 uses of mifepristone medical abortions, which is far less fatal than penicillin-induced anaphylaxis (1 in 50,000 uses). Few direct

34

comparisons of surgical and medical abortions are available, but using the data from the distributor of the mifepristone, 11 pregnancy-related deaths occurred in 1.8 million medical terminations from approximately 2000-2011, with a mortality rate of 0.7/100,000, which is virtually identical to the rate of mortality from surgical abortions. CervicitisBackground Cervicitis is an inflammation of the uterine cervix, characteristically diagnosed by: (1) a visible, purulent or mucopurulent endocervical exudate in the endocervical canal or on an endocervical swab specimen and/or (2) sustained, easily induced endocervical bleeding when a cotton swab is gently passed through the cervical os.[1] A normal cervix is pictured below. (See Presentation.)

Normal cervix Noninfectious cervicitis Noninfectious cervicitis can be caused by the following:

Local trauma - Eg, cervical irritation caused by tampons, a cervical cap, the string from an intrauterine contraceptive device, a pessary, or a diaphragm Radiation Chemical irritation - Eg, vaginal douches, latex exposure, or contraceptive creams

35

Systemic inflammation - Eg, Behet syndrome Malignancy Infectious cervicitis The infectious etiologies of cervicitis, all of which are sexually transmitted infections (STIs), are significantly more common than the noninfectious causes. This article focuses on the infectious etiologies of cervicitis. (See Etiology.)

Infectious cervicitis may be caused by Chlamydia trachomatis (see the first image below), Neisseria gonorrhoeae,herpes simplex virus (HSV) (see the second image below), or human papillomavirus (HPV). In most cases of cervicitis, however, lab tests fail to isolate an organism; this is particularly true in women with low risk factors. (See Etiology and Workup.)[1]

Signs of chlamydial cervicitis on speculum examination may include mucopurulent endocervical discharge and spontaneous or easily induced endocervical

bleeding or any zones of ectopy. Herpes simplex virus (HSV) cervicitis may involve the exocervix or endocervix, and it may be symptomatic or asymptomatic.

36

Usually, the cervix appears abnormal to inspection, with diffuse vesicular lesions, ulcerative lesions, erythema, or friability. Trichomonas vaginalis, which, technically, causes vaginal infections, is commonly included in the discussion of cervicitis. Because the female genital tract is contiguous from the vulva to the fallopian tubes, there is some overlap between vulvovaginitis and cervicitis; both conditions are commonly categorized as lower genital tract infections. Infections involving the endometrium and fallopian tubes are commonly categorized as upper genital tract infections and are not discussed in this article. (See DDx.) Etiology The most common etiologies of cervicitis are infectious, with sexual transmission of organisms such as with C trachomatis and N gonorrhoeae being the primary means by which it is spread.[1] Other etiologic organisms include Trichomonas vaginalis and herpes simplex virus (HSV), especially primary type 2 HSV.[1] Noninfectious causes of cervicitis include local trauma, radiation, chemical irritation, systemic inflammation, and malignancy. Limited data exist to suggest frequent douching, as well as Mycoplasma genitalium infection and bacterial vaginosis, as potential causes.[1] Risk factors Risk factors for cervicitis include the following:

37

Multiple sex partners Young age Single marital status Urban residence Low socioeconomic status Alcohol or drug use Genetic predisposition, largely due to a variable host immune response, also plays an important role in the variability in infectious complications.[2] Variants in the genes that regulate toll-like receptors (TLRs), an important component in the innate immune system, have been associated with an increased progression of C trachomatis infection to pelvic inflammatory disease (PID).[3]

Vulvovaginitis Background Vulvovaginitis is the most common gynecologic condition seen by practitioners rendering primary care to women. The term vulvovaginitis is a semantic compromise that categorizes many vaginal infections as vulvovaginitis because the 2 are interrelated. Discharge, burning, and pruritus are the most common symptoms, accompanied by signs of vulvar irritation such as erythema and excoriation of the vulvar skin. Traditionally, the 3 classic entities of vaginitis include bacterial vaginosis,Trichomonas infection, and candidiasis. However, this article focuses on topics that are primarily inflammatory disorders and affect the vulvar region. Pathophysiology

38

The vulva, the external genitalia of the female, includes the labia majora and minora, the clitoris, and the vestibule of the vagina. During the reproductive years of a healthy woman's life, the vagina maintains a moist environment that is in constant fluctuation. The secretion of an alkaline transudate from the vaginal epithelium and cervical glands maintains this moist environment with a pH ranging from 3.8-4.5. In addition, the vagina and its microflora form a unique balanced environment that can change under pressure from external stimuli but returns to normal with removal of the stimuli. It can vary in degree during the menstrual cycle, pregnancy, and sexual activity. The vaginal epithelium consists of 3 cell layers: superficial, intermediate, and basal. These cells are capable of storing glycogen under the influence of estrogen. Glycogen is available in the fully mature cells in the superficial layer of the epithelium. With elevated levels of either exogenous or endogenous estrogen, all levels of the epithelium thicken as a result of glycogen storage. With diminishing levels of estrogen, the layers become thin and atrophic. In an adult woman's reproductive years, the bacterial flora of the healthy vagina contains numerous microorganisms, including aerobic and anaerobic gram-positive and gramnegative bacteria. Lactobacillus and Corynebacterium predominate over other bacteria such as Streptococcus, Bacteroides, Staphylococcus, andPeptostreptococcus. Both Lactobacillus and Corynebacterium produce lactic and acetic acid from glycogen, thus maintaining the low vaginal

39

pH. Additional bacteria are kept in check by the acidproducing bacteria and are rarely pathogenic, but they may become pathogenic if the environmental balance is affected. The skin of the vulva is sensitive to the vaginal environment and hormonal, metabolic, and allergic influences. It is composed of stratified squamous epithelium that contains hair follicles, sebaceous sweat glands, and apocrine glands. Notable bruising without known injury o Bleeding of oral cavity or gastrointestinal tract without obvious lesion o Epistaxis greater than 10 minutes duration (possibly necessitating packing or cautery) If a bleeding disorder is suspected, consultation with a hematologist is suggested.
o

Differential Diagnoses

Abortion Adnexal Tumors Adrenal Adenoma Adrenal Carcinoma Anovulation Cervicitis Endometrial Carcinoma Endometritis Gestational Trophoblastic Neoplasia Hyperprolactinemia Hyperthyroidism Hypothyroidism Obesity

40

Pelvic Inflammatory Disease Pituitary Microadenomas Pregnancy Diagnosis Uterine Cancer Vaginitis Patients with vaginitis almost always present with a chief complaint of abnormal vaginal discharge. Ascertain the following attributes of the discharge:

Quantity Duration Color Consistency Odor Obtain a history of the following:

Previous similar episodes Sexually transmitted infection Sexual activities Birth control method Last menstrual period Douching practice Antibiotic use General medical history Systemic symptoms (eg, lower abdominal pain, fever, chills, nausea, and vomiting) Bacterial vaginosis

Bacterial vaginosis is asymptomatic in up to 50% of women. If a discharge is present, it is typically thin, homogeneous, malodorous, and grayish white or yellowish white in color.

41

Vaginal pain or vulvar irritation is uncommon. Pruritus may occur. Bacterial vaginosis is common in pregnant women and is associated with preterm birth. In pregnant women with symptomatic bacterial vaginosis who have a history of preterm birth, administration of treatment early in pregnancy has been shown to decrease the incidence of preterm birth. Vaginal candidiasis Candidiasis is a fungal infection common in women of childbearing age. Pruritus is the most common symptom. This is accompanied by a thick, odorless, white vaginal discharge (with an appearance similar to that of cottage cheese), which can be minimal. Usually, associated vulvar candidiasis is present, commonly with vulvar burning, dyspareunia, and vulvar dysuria (a burning sensation arising when urine comes into contact with vulvar skin). Patients often have a history of recurrent yeast infection or recent antibiotic treatment. Symptoms of candidiasis often begin just before menses. Precipitating factors include immunosuppression, diabetes mellitus, pregnancy, and hormone replacement therapy. Candidiasis is usually not contracted from a sexual partner. About 75% of all women have at least 1 episode of candidiasis in their lifetime. Recurrent episodes may indicate underlying immunodeficiency or diabetes. Trichomoniasis

42

T vaginalis infection is the most common nonviral STD in the world. Many patients (20-50%) are asymptomatic. If discharge is present, it is usually copious and frothy and can be white, gray, yellow, or green (the yellow and green colors are due to the presence of white blood cells [WBCs]). Local pain and irritation are common. Dysuria (20%), pruritus (25%), and postcoital bleeding due to cervicitis are other possible symptoms. Symptoms often peak just after menses. Trichomoniasis is associated with risk factors for other STDs; accordingly, a history of multiple sexual partners should be elicited. Infection during pregnancy has been associated with preterm deliveries and low-birth-weight infants. Trichomoniasis is rare in prepubertal children. Sexual abuse should be suspected if symptoms are present. Symptoms include a copious frothy discharge, local pain, irritation, and, occasionally, pruritus. Other conditions In women with chronic vaginitis, atrophic vaginitis and hypoestrogenism must be considered. Elicit an accurate menstrual history. Vulvovaginitis has multiple nonvenereal causes in prepubertal children; however, if a vaginal discharge suggests an STD, question all children (or their caretakers) regarding possible sexual abuse. Symptoms of vulvovaginitis in prepubertal girls generally include localized pain, dysuria, pruritus, erythema, and discharge.

43

Bacteria that can cause vulvovaginitis include streptococcal species (including group A streptococci), Escherichia coli, and Shigella sonnei. Symptoms (eg, pharyngitis and diarrhea) may result from infections in areas of the body other than the vagina. A Shigella infection may result in a bloody vaginal discharge without symptoms of diarrhea. A patient with group A streptococcal infection may present with itching or painful defecation. Purulent discharge may develop insidiously. Viral infections may cause symptoms of vulvovaginitis. Elicit a history of recent viral infections, including varicella. Herpes simplex viruses (HSVs), particularly HSV-1 transmitted via autoinoculation from the oral mucosa, might be present; elicit a history of recurrent oral herpes or digital herpes in the caretaker of a child in diapers. If candidal vulvovaginitis is considered (it is rare in healthy prepubertal girls), the history should include recent antibiotic use, possible diabetes mellitus, immunosuppression, and underlying skin disease. Ask about a family history of mucocutaneous candidiasis. Consider helminthic infections (eg, Enterobius vermicularis infections) resulting in pruritus of the genital area. Ask about contact with pinworm-infected children, itching (particularly at night), and vaginal pain. Ask questions to exclude the possibility of a foreign body in the vagina, chemical irritation (eg, recent bubble baths, washing hair with shampoo while bathing, douching, use of feminine hygiene sprays), latex, semen, mechanical

44

irritation, and poor hygiene. Foreign bodies in the vagina result in a persistent, foul-smelling, serosanguineous discharge. Contact dermatitis from unusual exposures may occur; ask about this possibility and about bathing patterns. Obtain a history of recent trauma to the vaginal area and a history of urination and defecation patterns and problems to exclude possible anatomic abnormalities (eg, rectovaginal fistula). Lichen sclerosis et atrophicus may be seen in prepubertal children and in postmenopausal women. Symptoms of chronic fissures, pain, or pruritus are often present. Rectal fissures may lead to chronic constipation in children. Physical Examination The physical examination of pubertal and adult women should include a complete pelvic examination. The Tanner stage of development should be noted. The examination for prepubertal girls should be performed as described in Pediatrics, Child Sexual Abuse. Bacterial vaginosis Physical findings in bacterial vaginosis include a homogeneous, frothy vaginal discharge that is grayish-white to yellowish-white in color. The discharge appears adherent to the vaginal mucosa. Typically, no underlying erythema exists. As many as 50% of women with bacterial vaginosis are asymptomatic. Bacterial vaginosis can be diagnosed if 3 of the following 4 Amsel criteria are present (see Workup):

45

Homogeneous, white, adherent discharge Vaginal pH higher than 4.5 Amine (fishy) smell from vaginal discharge when potassium hydroxide (KOH) is added (whiff test) Clue cells on wet mount Vaginal candidiasis

Vaginal candidiasis may present with a well-demarcated erythema of the vulva with satellite lesions (discrete pustulopapular lesions) surrounding the redness. The vulva, vagina, and surrounding areas may be edematous and erythematous, possibly accompanied by excoriations and fissures. A thick, adherent, cottage cheeselike vaginal discharge may be seen. The cervix usually appears normal. Trichomoniasis In trichomoniasis, the vulva may appear erythematous and edematous, with excoriation. Look for a copious, frothy, homogeneous vaginal discharge that can be white, gray, yellow, or green. Small punctate cervical and vaginal hemorrhages with ulcerations may be observed. So-called strawberry cervix, or colpitis macularis, is highly specific for Trichomonas infection, and 2-5% of patients will have this finding on examination. Because diagnosis of Trichomonas infection on the basis of clinical signs and symptoms is unreliable, laboratory confirmation is mandatory. Other conditions

46

Physical findings associated with cervicitis from STDs include excessive vaginal discharge, erythema, and edema of the cervix. Fever, cervical motion, or abdominal or adnexal tenderness may indicate upper genital tract infection (eg, cervicitis or PID). Cervical ectopy or eversion may cause discharge with no apparent infectious cause. Physical findings associated with atrophy, dysplasia, and vulvar vestibulitis syndrome include localized atrophy or infection in skin and mucous membranes. In about 50% of all cases of mucopurulent discharge in women, the etiology is unknown. Vaginal foreign bodies in adults include forgotten tampons; in children, pieces of toilet tissue typically are found. Findings of foul odor and irritation with a purulent discharge are common. A patient with pinworms may present with few physical findings. Occasionally, there may be erythema and excoriations around the perianal area. In severe cases, eggs or dead female nematodes may be seen on examination of the anal area. Perianal streptococcal dermatitis usually results in a beefyred perineal area that is edematous and tender. Fissures, drainage, and hemorrhagic spotting may be present. Complications Bacterial vaginosis has been associated with pelvic inflammatory disease (PID), endometritis, and vaginal cuff cellulitis when invasive procedures have been performed.

47

Such procedures include endometrial biopsies, cesarean section, uterine curettage, and intrauterine device (IUD) placement. During pregnancy, bacterial vaginosis and trichomoniasis are associated with an increased risk of premature rupture of membranes, preterm labor,[4] low birth weight, and preterm delivery. Systemic disease resulting from the spread of gonorrhea may occur.

Menorrhagia Menorrhagia DEFINISI Anda mungkin pernah mengalami pendarahan yang berat pada saat menstruasi. Jika anda seperti beberapa orang wanita yang kehilangan banyak darah dan rasa sakit yang menggaggu aktifitas anda, maka istilah medis untuk hal ini adalah menorrhagia. Menorrhagia sering terjadi karena ketidakseimbangan

48

hormon yang menyebabkan siklus mentruasi tanpa adanya ovulasi. Normalnya pelepasan sel telur dari ovarium merangsang tubuh menghasilkan progesteron. Tanpa sel telur, tidak cukupnya kadar progesteron dapat menyebabkan pendarahan berat saat menstruasi. Jika anda mengalami pendarahan yang berat pada saat menstruasi dan menyebabkan anda mengalami rasa takut dengan kondisi ini, bicaralah pada dokter anda karena ada banyak pengobatan efektif untuk merawat menorrhagia.

GEJALA Tanda dan gejala menorrhagia antara lain: Aliran darah menstruasi membasahi satu atau lebih pembalut setiap jam untuk beberapa jam secara berturutturut. Membutuhkan pembalut yang berlapis untuk mengontrol aliran darah yang keluar. Perlu mengganti pembalut secara sering pada saat malam hari. Periode menstruasi berhenti dalam waktu lebih dari tujuh hari. Terdapat gumpalan darah. Mempengaruhi aktifitas rutin sehari-hari. Kelelahan, lemah atau napas pendek (gejala anemia)

49

Penyebab & Faktor Risiko Penyebab Ketidakseimbangan hormon. Ketidakseimbangan hormon estrogen dan progesteron dapat menyebabkan menorrhagia. Disfungsi ovarium. Ovulasi yang tidak normal dapat menyebabkan ketidakseimbangan hormon. Uterine fibroids. Tumor jinak di dalam uterus dapat menyebabkan menstruasi yang tidak normal. Polip. Polip yang tumbuh di dinding uterus dapat menyebabkan menstruasi yang berat dan lama. Adenomyosis.Kondisi ketika kelenjar dari endometrium terdapat di dinding uterus dan sering menyebabkan pendarahan berat dan rasa sakit. Intrauterine device (IUD). Penggunaan alat KB nonhormonal IUD dapat menyebabkan terlalu besarnya pendarahan yang terjadi pada saat menstruasi. Komplikasi kehamilan. Kehamilan ectopic kehamilan yang terjadi bukan di rahim juga menyebabkan menorrhagia. Gangguan pendarahan bawaan. Beberapa penyakit

50

pengentalan darah seperti von Willebrands disease menyebabkan ketidaknormalan pendarahan saat menstruasi. Obat. Obat tertentu antara lain obat anti pembengkakan dan pencegah gumpalan darah dapat menyebabkan pendarahan berat dan menstruasi yang panjang. Kondisi medis lain. Beberapa kondisi medis, antara lain pelvic inflammatory disease (PID), thyroid problems, endometriosis, dan penyakit ginjal atau hati dapat menyebabkan menorrhagia.

Faktor risiko Gadis remaja yang baru saja memulai menstruasi. Wanita menjelang masa menopause.

Background Dysfunctional uterine bleeding (DUB) is irregular uterine bleeding that occurs in the absence of pathology or medical illness. It reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining. The bleeding is unpredictable in many ways. It might be excessively heavy or light, prolonged, frequent, or random. This condition usually is associated with anovulatory menstrual cycles but also can present in patients with oligoovulation. DUB occurs without recognizable pelvic

51

pathology, general medical disease, or pregnancy. It is considered a diagnosis of exclusion. Pathophysiology Patients with dysfunctional uterine bleeding (DUB) have lost cyclic endometrial stimulation that arises from the ovulatory cycle. As a result, these patients have constant, noncycling estrogen levels that stimulate endometrial growth. Proliferation without periodic shedding causes the endometrium to outgrow its blood supply. The tissue breaks down and sloughs from the uterus. Subsequent healing of the endometrium is irregular and dyssynchronous. Chronic stimulation by low levels of estrogen will result in infrequent, light DUB. Chronic stimulation from higher levels of estrogen will lead to episodes of frequent, heavy bleeding. Epidemiology Frequency United States Dysfunctional uterine bleeding is a common diagnosis, making up 5-10% of cases in the outpatient clinic setting. Mortality/Morbidity Single episodes of anovulatory bleeding generally carry a good prognosis. Patients who experience repetitive episodes might experience significant consequences. Frequent uterine bleeding will increase the risk for iron deficiency anemia. Flow can be copious enough to require hospitalization for

52

fluid management, transfusion, or intravenous hormone therapy. Chronic unopposed estrogenic stimulation of the endometrial lining increases the risk of both endometrial hyperplasia and endometrial carcinoma. Timely and appropriate management will prevent most of these problems. Many individuals with dysfunctional uterine bleeding are exposed to unnecessary surgical intervention, such as repeated uterine curettage, endometrial ablative therapy, or hysterectomy, before adequate workup and a trial of medical therapy can be completed. Iron deficiency anemia: Persistent menstrual disturbances might lead to chronic iron loss in up to 30% of cases. Adolescents might be particularly vulnerable. Up to 20% of patients in this age group presenting with menorrhagia might have a disorder of hemostasis. Endometrial adenocarcinoma: About 1-2% of women with improperly managed anovulatory bleeding eventually might develop endometrial cancer. Infertility associated with chronic anovulation, with or without excess androgen production, is frequently seen in these patients. Patients withpolycystic ovarian syndrome, obesity, chronic hypertension, and insulin-resistant diabetes mellitus particularly are at risk. Sex

The condition only affects females. Age

53

Because most cases are associated with anovulatory menstrual cycles, adolescents and perimenopausal women are particularly vulnerable. About 20% of affected individuals are in the adolescent age group, and 50% of affected individuals are aged 40-50 years. History Suspect dysfunctional uterine bleeding (DUB) when a patient presents with unpredictable or episodic heavy or light bleeding despite a normal pelvic examination. Typically, the usual moliminal symptoms that accompany ovulatory cycles will not precede bleeding episodes. Exclude the diagnosis of pregnancy first. Address the presence of local and systemic disease. Rule out the presence of signs or symptoms indicative of bleeding disorders. Screening for personal and family history of easy bruising, bleeding gums, epistaxis, and excessive bleeding episodes during childbirth, surgery, or dental procedures may be useful. Rule out iatrogenic causes of bleeding, including bleeding secondary to steroid hormone contraception, hormone replacement therapy, or other hormone treatments, which are common causes. Most patients are adolescents or are older than 40 years. Patients who report irregular menses since menarche may have polycystic ovarian syndrome (PCOS). PCOS is characterized by anovulation or oligo-ovulation and hyperandrogenism. These patients often present with unpredictable cycles and/or infertility, hirsutism with or without hyperinsulinemia, and obesity.

54

Patients with adrenal enzyme defects, hyperprolactinemia, thyroid disease, or other metabolic disorders also might present with anovulatory bleeding. Physical The physical examination can elicit several anatomic and organic causes of abnormal uterine bleeding. A complete physical examination should begin with assessment of hemodynamic stability (vital signs) and proceed with evaluation of the following: o Obesity (BMI) o Signs of androgen excess (hirsutism, acne) o Thyroid enlargement or manifestations of hyperthyroidism or hypothyroidism. o Galactorrhea (may suggest hyperprolactinemia) o Visual field deficits (raise suspicion of intracranial/pituitary lesion) o Ecchymosis, purpura (signs of bleeding disorder) o Signs of anemia or chronic blood loss A careful gynecologic examination, including Papanicolaou test (Pap smear) and sexually transmitted disease (STD) screening, is warranted. The hallmark of DUB is a negative pelvic examination despite the clinical history. In such cases, management might rest on a clinical diagnosis. o Rule out the presence of uterine fibroids or polyps. o Rule out endometrial hyperplasia or carcinoma.

55

Causes In ovulatory cycles, progesterone production from the corpus luteum converts estrogen primed proliferative endometrium to secretory endometrium, which sloughs predictably in a cyclic fashion if pregnancy does not occur. Heavy but regular uterine bleeding implies ovulatory bleeding and should not be diagnosed as DUB. Subtle disturbances in endometrial tissue mechanisms, other forms of uterine pathology, or systemic causes might be implicated. Anovulatory cycles are associated with a variety of bleeding manifestations. Estrogen withdrawal bleeding and estrogen breakthrough bleeding are the most common spontaneous patterns encountered in clinical practice. Iatrogenically induced anovulatory uterine bleeding might occur during treatment with oral contraceptives, progestin-only preparations, or postmenopausal steroid replacement therapy. Estrogen breakthrough bleeding o Anovulatory cycles have no corpus luteal formation. Progesterone is not produced. The endometrium continues to proliferate under the influence of unopposed estrogen. o Eventually, this out-of-phase endometrium is shed in an irregular manner that might be prolonged and heavy. This pattern is known as estrogen breakthrough bleeding and occurs in the absence of estrogen decline. Estrogen withdrawal bleeding o This frequently occurs in women approaching the end of reproductive life.

56

In older women, the mean length of menstrual cycle is shortened significantly due to aberrant follicular recruitment, resulting in a shortened proliferative phase. Ovarian follicles in these women secrete less estradiol. Fluctuating estradiol levels might lead to insufficient endometrial proliferation with irregular menstrual shedding. This bleeding might be experienced as light, irregular spotting. o Eventually, the duration of the luteal phase shortens, and, finally, ovulation stops. Dyssynchronous endometrial histology with irregular menstrual shedding and eventual amenorrhea result. Oral contraceptives, progestin-only preparations, or postmenopausal steroid replacement therapy o Treatment with oral contraceptives, progestin-only preparations, or postmenopausal steroid replacement therapy might be associated with iatrogenically induced uterine bleeding. o Progesterone breakthrough bleeding occurs in the presence of an unfavorably high ratio of progestin to estrogen. o Intermittent bleeding of variable duration can occur with progestin-only oral contraceptives, depomedroxyprogesterone, and depo-levonorgestrel. o Progesterone withdrawal bleeding can occur if the endometrium initially has been primed with endogenous or exogenous estrogen, exposed to progestin, and then withdrawn from progestin. Such a pattern is seen in cyclic hormonal replacement therapy. Adolescents
o

57

The primary defect in the anovulatory bleeding of adolescents is failure to mount an ovulatory luteinizing hormone (LH) surge in response to rising estradiol levels. Failure occurs secondary to delayed maturation of the hypothalamic-pituitary axis. Because a corpus luteum is not formed, progesterone levels remain low. o The existing estrogen primed endometrium does not become secretory. Instead, the endometrium continues to proliferate under the influence of unopposed estrogen. Eventually, this out-of-phase endometrium is shed in an irregular manner that might be prolonged and heavy, such as that seen in estrogen breakthrough bleeding. Climacteric o Anovulatory bleeding in menopausal transition is related to declining ovarian follicular function. o Estradiol levels will vary with the quality and state of follicular recruitment and growth. o Bleeding might be light or heavy depending on the individual cycle response. Bleeding disorders: An international expert panel including obstetrician/gynecologists and hematologists has issued guidelines to assist physicians in better recognizing bleeding disorders, such as von Willebrand disease, as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder.[1] Historically, a lack of awareness of underlying bleeding disorders has led to underdiagnosis in women with abnormal reproductive tract bleeding. The panel provided expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. An underlying
o

58

bleeding disorder should be considered when a patient has any of the following: o Menorrhagia since menarche o Family history of bleeding disorders o Personal history of 1 or more of the following: Notable bruising without known injury Bleeding of oral cavity or gastrointestinal tract without obvious lesion Epistaxis greater than 10 minutes duration (possibly necessitating packing or cautery) o If a bleeding disorder is suspected, consultation with a hematologist is suggested. Menorrhagia (Darah Menstruasi Terlalu Banyak) Menorrhagia adalah istilah untuk perdarahan menstruasi yang berlebihan yaitu kehilangan lebih dari 80ml selama periode menstruasi. Studi populasi menunjukkan bahwa kehilangan darah menstruasi yang normal adalah 30-40 ml. Kondisi yang berkaitan yang mungkin tumpang tindih dengan menorrhagia meliputi: Metrorrhagia aliran yang tidak teratur atau sering, nonsiklik Menometrorrhagia sering, berlebihan, aliran tidak teratur (menorrhagia ditambah metrorrhagia) Polymenorrhea aliran sering, siklus 21 hari atau kurang

59

Intermenstrual perdarahan Perdarahan menstruasi yang teratur antara Rahim disfungsional pendarahan (DUB) perdarahan endometrium abnormal menyebabkan hormon dan terkait dengan anovulasi Penelitian telah menunjukkan bahwa pasien dengan menorrhagia memiliki peningkatan dalam aliran darah menstruasi selama tiga hari pertama (hingga 92% dari total menstruasi yang hilang pada saat itu). Hal ini menunjukkan bahwa mekanisme yang bertanggung jawab untuk berhenti menstruasi adalah sebagai efektif pada wanita yang memiliki menorrhagia seperti pada perempuan normal, meskipun kehilangan darah yang sangat banyak. Kondisi yang berkaitan yang mungkin tumpang tindih dengan menorrhagia meliputi: Metrorrhagia aliran yang tidak teratur atau sering, nonsiklik Menometrorrhagia sering, berlebihan, aliran tidak teratur (menorrhagia ditambah metrorrhagia) Polymenorrhea aliran sering, siklus 21 hari atau kurang Intermenstrual perdarahan Perdarahan menstruasi yang teratur antara Rahim disfungsional pendarahan (DUB) perdarahan endometrium abnormal menyebabkan hormon dan

60

terkait dengan anovulasi Menentukan kehilangan darah Anda Studi yang telah mengukur kehilangan darah telah menunjukkan bahwa pasien dengan menorrhagia memiliki peningkatan dalam aliran darah menstruasi selama tiga hari pertama (hingga 92% dari total menstruasi yang hilang pada saat ini). Hal ini menunjukkan bahwa mekanisme yang bertanggung jawab untuk berhenti menstruasi adalah sebagai efektif pada wanita yang memiliki menorrhagia seperti pada perempuan normal, meskipun kehilangan darah yang sangat banyak. Penyebab : Kemungkinan penyebab termasuk yang terkait dengan perubahan hormon seperti estrogen terlalu banyak atau prolaktin, terlalu sedikit atau buruk waktunya hormon luteinizing, dan penyakit ovarium polikistik. Penyebab fisik termasuk obesitas atau kehadiran fibroid, hiperplasia endometrium, polip, kanker, endometriosis, kehamilan ektopik, dan menggunakan IUD.Gangguan perdarahan seperti kekurangan vitamin K atau penggunaan pengencer darah dapat memberikan kontribusi faktor. hipotiroidisme, defisiensi zat besi, dan kekurangan vitamin A. Perdarahan berat dapat disebabkan oleh estrogen

61

terlalu banyak atau terlalu sedikit progesteron. Terlalu banyak estrogen menyebabkan pertumbuhan berlebihan dari lapisan endometrium yang kaya darah yang akan dikeluarkan setiap bulan. Diagnosis dan Tes Ketika telah ditetapkan bahwa penyebabnya adalah tidak organik (kondisi fisik), laboratorium pengujian (waktu perdarahan, hitung darah lengkap, dan fungsi tiroid) harus dilakukan, dan setiap kelainan dikoreksi.lebih atau kurang dari biasanya, sulit untuk secara akurat menentukan kehilangan darah yang sebenarnya menggunakan perkiraan berdasarkan jumlah tampon atau pembalut yang digunakan. Satu studi menunjukkan bahwa 26% dari wanita dengan hilangnya periode menstruasi normal dianggap mereka berat, sementara 40% dari mereka dengan kerugian besar dianggap periode mereka untuk menjadi moderat atau ringan. [Acta Obstet Gynecol Scand 1966; 45: pp.320-51] Threatment/perawatan yang dibutuhkan untuk Menorrhagia: Herbal/botanical : bisa menggunakan vitex agnus cactus, yang mana herbal ini menyeimbangkan hormon2. jadi herbal ini sangat effective untuk penderita menorrhagia. meskipun diperlukan untuk

62

memakai vitex ini untuk beberapa (2-3) bulan untuk memperoleh efek. Mineral: memperbanyak konsumsi makanan yg kaya akan zat besi. Vitamin : -vitamin A Dalam satu studi, serum retinol kadar (ukuran vitamin A level)ditemukan secara signifikan lebih rendah pada wanita denganmenorrhagia daripada kelompok kontrol sehat. Seseorang tidakboleh melebihi 10.000 IU per hari jika beresiko menjadi hamil. - Vitamin C, bioflavonoid Kerapuhan kapiler diyakini memainkan peran dalam banyak kasus menorrhagia. Suplementasi dengan vitamin C dan bioflavonoid telah terbukti mengurangi menorrhagia. Seperti vitamin C dikenal untuk secara signifikan meningkatkan penyerapan zat besi, efek terapeutik juga dapat terjadi karena penyerapan zat besi ditingkatkan. - vitamin E Radikal bebas mungkin memiliki peran penyebab dalamperdarahan endometrium, terutama dengan

63

adanya alat kontrasepsi dalam rahim. Satu studi menunjukkan bahwa suplementasi dengan 100 IU untuk 10 minggu menghasilkan peningkatan pada semua pasien. [Int J Fertil 1983; 28: pp.55-6], Perhatian harus dilakukan sebagai dosis tinggi memiliki efek pengencer darah jadi di jangan terlalu banyak dosis vitamin, cukup dengan 100IU saja.