ABNORMALITY OF

MENSTRUAL CYCLE

Abnormality :
Cycles
Period
Amount of bleeding
Pain associated with menses

Disorders of the Menstrual Cycle

Amenorrhea
Dysmenorrhea
Premenstrual Syndrome
Abnormal Uterine Bleeding

Abnormal Uterine Bleeding: Definitions

Menorrhagia: Heavy or prolonged uterine bleeding that
occurs at regular intervals. Some sources define further
as the loss of 80 mL blood per cycle or bleeding > 7
days.
Hypomenorrhea: Periods with unusually light flow, often
associated with hypogonadotropic hypogonadism
(athletes, anorexia). Also may be associated with
Ashermans syndrome
Metrorrhagia: Irregular menstrual bleeding or bleeding
between periods
Menometrorrhagia: Metrorrhagia associated with > 80
mL
Polymenorrhea: Frequent menstrual bleeding. Strictly,
menses occur q 21 d or less
Oligomenorrhea: Menses are > 35 d apart. Most
commonly caused by PCOS, pregnancy, and anovulation

Abnormal Uterine Bleeding: Differential Diagnosis

Structural
Cervical or vaginal laceration
Uterine or cervical polyp
Uterine leiomyoma
Adenomyosis
Cervical stenosis/Ashermans (hypomenorrhea)
Hormonal
Anovulatory bleeding
Hypogonadotropic hypogonadism
Pregnancy
Hormonal Contraception (i.e. OCPs, Depo-Provera)
Thyroid disorders
Hyperprolactinemia
Malignancy
Uterine or Cervical cancer
Endometrial hyperplasia (potentially pre-malignant)
Bleeding disorders
von Willebrands Disease, Hemophilia/Factor deficiencies,
platelet disorders

How to approach the diagnosis ?

Anamnesis :
- Chief complain
- History of menstrual cycles
- Family history of abnormality of menstruation
- Developmental disorders
- History of other disease
- History of medication including contraception
- Psychological disorders

- Physical examination
- Laboratory diagnostic
-

USG
Laparoscopy
X-Ray
CT Scan
Colposcopy
MRI

Therapy : - Depend on etiology

- Induction of menstruation

AMENORHEA
Definition
1. Do not reach menarche, without secondary
sexual development until 13 years old
2. Until 15 years old with secondary sexual
development, but not reach menarche
3. absence of periods for a length of time
equivalent to a total of at least three of
the previous cycle intervals or 6 months of
amenorrhea

Classification (classical)
Primary amenorhea : Not have reach menarche
at all
Secondary amenorhea : Had a menstruation
before than stop.
a. Physiologically : Puerpuerium
Breast feeding
During pregnancy
Menopause
b. Pathologically : Other causes.
Amenorhea could be followed by galactorhea and
hirsutism.

Causes of Amenorrhea
Disorders of sexual differentiation
Distal genital tract obstruction
Gonadal dysgenesis
Ambiguity of external genitalia
Other peripheral causes
Pregnancy
Gestational trophoblastic disease
Asehermans syndrome

Causes of Amenorrhea
Chronic anovulation or ovarian failure
Due to CNS-hypothalamic-pituitary
dysfunction
Due to inappropriate feedback (PCOS)
Due to thyroid and adrenal disordes
Persumtive ovarian failure

DISMENORHEA
Definition
Pain that feel just before or on menstruation
Classification :
Primary dismenorhea/functional/idhiopatic :
pain that have no pathological causes
Secondary dismenorhea
Caused by factor that could be found

Etiology :
Prostaglandin theory F2-
Prostaglandin elevated the end of menstrual
cycles caused contraction of uterus
ischemia
pain.
Secondary dismenorhea
Could be caused by :
- Pelvic infection
- Endometriosis
- Myoma
- IUD
- Endometrial polyp

Treatment : Symptomatic
Endocrinology
Operative
Psychology
Symptomatic treatment :
- Analgesic
- Sedative
- Antispasmodic
- Diuretic
- Light exercises
- Bed rust
- Oral contraceptive
- Tocolytic
- Panasacral neurectomy

DISFUNGTIONAL UTERINE BLEEDING

Definition
Is an abnormal bleeding from uterus that
came only by hormonal disturbance without
organic abnormalities.
Happen in teenagers, reproductive period and
premenopause period.

Clasification :

1. DUB in anovulation cycles

Corpus luteum do not developed, level of estrogen is
high, progesteron level is low.
2. DUB in ovulation cycles
- midcycles bleeding
- Bleeding cause by disturbance in endometrial
release
- Spotting premenstruation and postmenstruation.
3. DUB in persistent follicles
- often found in reproductive line
- Endometrial hyperplasia : -Simplex
- Cystic
- Atypical

How to reach diagnosis

1. Anamnesis, gynecological examination
2. Anovulation diagnosis

Basal temperature : monophasic

Progestin level
: low
Gonadotropin level : LH low
Hyperfunction of adrenal : high testosteron
Hypothyroid
: high TSH
Endometrial Biopsy : atrophy, proliferate
Mittelschmeric
: absent
Menstrual cycles
: irregular.

Treatment

Hormonal therapy combination estrogen and

progesteron

OTHER DISTURBANCE
I. Pseudoamenorhea / Kriptomenorhea
Definition
There is menstruation, but the blood could not
expelled became blockade on cervix, vagina,
hymen.

Classification
- Congenital
- Acquisita : a. Infection (GO, diphtheria)
b. Abnormal delivery
c. Senility
Diagnosis :
Molimina menstrualia
Hematokolpos Hematometra
Hematosalphing
Treatment :
Incision/excision of blockade hymen

II. Menstrual Praecock

Definition
Bleeding in below 10 years child, accompanied by
secondary sexual development.
Classification :
a. Puberty praecock
Gonadotropin is formed, could get pregnant
Idiopathic
Central puberty praecock
Albright syndrome
Neoplasm that produce gonadotropin

b. Pseudopuberty pracock
There is no gonadotropin, and no ovulation :
Granulosa cell tumors/techa cell tumor
Disturbance on suprarenal glands
Gonad therapy

IV. Polymenorhea
Short period, less than 21 days.
A. If the cycles is short, but regular :
- short of proliferation phase
- short of secretion phase
- both of them

B. Cycles that previously normal but become,

shorter
Happen in :
- Climacterium
- Puberty
- TBC
Therapy :
Estrogen on combination between
Estrogen and progesterone

Oligomenorhea
Menstruation rare, long cycles more that
2 months
Caused by :
- Prolonged follicular phase
- Prolonged luteal phase
- Both of them
Always think about pregnancy.
Menorhagia
Expelled blood in large amount in regular
menstrual cycles

Caused by :

Hypoplasia uteri
Asthenia
During or after diseases
Myoma
Hypertension
Decompensatio cordis
Infection
Hemophilia

Metrorhagia
Irregular bleeding do not associated with
menstrual cycles.
I. Caused by pregnancy
- Abortion
- Ectopic pregnancy
II. Not caused by pregnancy
Usually hormonal or organic.