disorders emory university月经失调埃默里大学课件

Menstrual Disorders,Oguchi A. Nwosu M.D. Assistant Profressor Emory Family Medicine Dept. 6/28/07,Menstrual Cycle,Definitions,Menorrhagia Excessive (80ml) uterine bleeding Prolonged (7days) regular DUB Abnormal Bleeding, no obvious organic cause usually anovulatory Oligomenorrhea Uterine bleeding occurring at intervals between 35 days and 6 months Amenorrhea No menses x at least 6 months Metrorragia, Menometrorrhagia, Polymenorrhea,Ovulatory vs Anovulatory cycles,Anovulatory Oligo or Amenorrhea +/- Menorrhagia Ovulatory Regular menstrual cycles (plus premenstrual symptoms such as dysmenorrhea and mastalgia,DUB,-Defn: Excessively heavy, prolonged or frequent bleeding of uterine origin that is not due to pregnancy, pelvic or systemic disease -Diagnosis of exclusion - Anovulatory -Usually extremes of reproductive life and in pts with PCOS,DUB pathophysiology,Disturbance in the HPO axis thus changes in length of menstrual cycle No progesterone withdrawal from an estrogen-primed endometrium Endometrium builds up with erratic bleeding as it breaks down.,16year old with daily heavy vaginal bleeding with clots, no cramps,5ft 7in, 105ibs, normal sec. sex xristics, pelvic normal Menarche 14, 2 periods last year, heavy lasts 2 weeks, virginal. I month hx of daily heavy vag bleeding with clots, 8 to 10 pads x day No associated symptoms,Picture of teenager,DUB management,HCG, CBC, TSH ? Coagulation workup Ensure pap smear UTD if appropriate 35 or Ca risk factors, tamoxifen use sample endometrium,DUB management,I/V or I/M conjugated estrogen therapy acute DUB-How ?!. Usually followed by OCP or progestin Cyclic progestins for 10 to 12 days each cycle, consider mirena IUD OCP D and C old school, no longer recommended.,Menorrhagia,-Heavy vaginal bleeding that is not DUB -Usually secondary to distortion of uterine cavity- heavy with or without prolongation (anatomic). Uterus unable to contract down on open venous sinuses in the zona basalis -Other causes organic, endocrinologic, hemostatic and iatrogenic -Usually ovulatory,40 year old with menorrhagia x 12 months,5ft5”, 155Ibs, husband castrated Had normal 28 day cycles lasting 5 days Last 1 year or so very heavy periods with clots and occ. flooding in the first 3 days with need to use 8pads/day fully soaked, spots for up to 1 week after this. Dysmenorrhea, severe, aching pain lower legs Normal recent pap,Picture of middle aged woman,Menorrhagia, Management,History Physical exam-anemia, obesity, androgen excess e.g. hirsuitism, acne, ecchymosis/purpura, thyroid, galactorrhea, liver/spleen, Pelvic- Uterine, cervical and adnexal,Menorrhagia, management,HCG, CBC, TSH ? Coagulation workup Ensure pap smear UTD if appropriate 35 or Ca risk factors, tamoxifen use sample endometrium Other tests as INDICATED by HX and PE,Endometrial evaluation of menorrhagia,Menorrhagia, medical management,NSAIDs, 1st line, 5 days, decrease prostaglandins Danazol, Androgen and prog. competitor , amenorrhea in 4-6 weeks, androgenic side effects OCPs, esp. if contraception desired, up to 60% dec. supp. HP axis Continous OCPs Oral continous progestins (day 5 to 26), most prescribed, antiestrogen, downregulates endormetrium Levonorgestrel IUD (Mirena), High satisfaction rate that approaches surgical techniques GnRH agonists, Inhibit FSH and LH release hypogonadism, bone Conjugated estrogens for acute bleeding Other treatments as indicated e.g. DDAVP for coagulation defects,Menorrhagia, surgical management,Menorrhagia, Surgical Management,Menorrhagia, management summary,Tailor treatment to individual patient. Consider patients age, coexisting medical diseases, FH, desire for fertility, cost of rx and adverse effects Surgical management reserved for organic causes (e.g fibroids) or when medical management fails to alleviate symptoms,Amenorrhea, physiologic causes,Male gender Prepubertal female Pregnant female Postmenopausal female,Primary Amenorrhea,Absence of menses by age 14 with absence of SSC (e.g. breast development) or absence by age 16 with normal SSC Only 3 conditions unique to primary, other causes of amenorrhea can cause either -Vaginal agenesis -Androgen insensitivity syndrome -Turners syndrome (45, X0),Amenorrhea, causes,Generalized pubertal delay e.g. Turner syndrome Normal puberty e.g. PCOS Abnormalities of the genital tract e.g. Ashermans syndrome,Amenorrhea, management,Hx. PE- These are probably the most important aspects in diagnosis Remember to always rule out pregnancy H & P suggests Ovarian-axis problem- TSH, prolactin, FSH, LH Hirsuitism-Testosterone, DHEAS, androstenedione and 17-OH progesterone Chronic ds.- ESR, LFTs, BUN, cr and UA CNS- MRI,Amenorrhea, management,If H and P gives no clues to diagnosis-exciting Use step wise approach to diagnosis,Evaluation of Secondary Amenorrhea,Abnormal Menstruation Heres what you need to remember!,Always R/O pregnancy, check pap Try to differentiate anovulatory from ovulatory bleeding Good history and physical is key( this applies to amenorrhea as well) Do a focused work up based on your H & P rather than a random set of studies In amenor