Disorders of the menstrual cycle doc

Chapte r 5

Disorders of the menstrual

cycle

Meiorrhagia

Dysmeiorrhoea

Amenorrlioea/oligomenorrhoea

43 Polycystic ovarian syndrome

49 Postmeiopausal bleediig

50 Premenstrual syndrome

53

55

56

OVERVIE W

Disorders of tie menstrual cycle are one of tie mosi common reasons lor women to attend their general practitioner aid, sub￾sequently, a gynaecologist. Although rarely life threatening, menstrual disorders lead to major social and occupational disruption,

and can also affect psychological well-being. Clinicians treating women with menstrual problems need not only to have a detailed

understanding of normal menstrual physiology, and the various disorders that commonly present (as detailed in this chapter), but

also to approach women with a presenting complaint of menstrual disorder in a compassionate and empathetic manner.'

MENORRHAGIA

Definition

The average menstrual period lasts for 3=2 s, with

i mean blood loss of 35 mL.

Menorrhagia ('heavy periods') is defined as a blood

-o=s of greater than 80 mL per period. This definition

B rather arbitrary, but represents the level of blood

loss at which a fall in haemoglobin and haematocrit

concentration commonly occurs.

Prevalence

Menorrhagia is extremely common. Indeed, each

war in the UK, 5 per cent of women between the ages

of 30 and 49 consult their general practitioner with

this complaint. Menorrhagia is the single leading

cause of referral to hospital gynaecology clinics.

lassification

Menorrhagia can be classified as:

• idiopathic, where no organic pathology can be

found: idiopathic menorrhagia is otherwise

known as dysfunctional uterine bleeding (DUB).

The majority of women who present with

menorrhagia will have DUB,

• secondary to an organic cause, such as fibroidi.

Despite extensive research, of

DUB remains unclear. Disordered endometnal

44 Disorders of the menstrual cycle

proslaglandin production has been implicated in the

aetiology of this condition, as have abnormalities of

endo met rial vascular development.

There are clearer reasons why many more women

complain of menorrhagia now than they did a cen￾tury ago. With decreasing family size, women now

experience many more menstrual cycles. Additionally,

the changing role of women in society and more lib￾erated attitudes to the discussion of sexual and repro￾ductive health mean that women are now much less

likely to tolerate menstrual loss that they consider to

be excessive.

Other physiology

Menorrhagia is a feature of a number of organic con￾ditions, which should be considered in the differen￾tial diagnosis. These include:

• von Willebrand's disease,

• other bleeding diatheses,

• fibroid uterus,

• endometrial polyp,

• thyroid disease,

• drug therapy, including intrauterine contraceptive

devices (lUCDs),

• bleeding in pregnancy.

History

The hallmark of nienorrhagia is the complaint of regu￾lar 'excessive' menstrual loss occurring over several

consecutive cycles. This is largely a subjective defin￾ition, and it can be hard for the woman to communi￾cate in words how much blood she is losing.

Discussion of the number of towels and tampons

used per day may be useful - perhaps accompanied

by a menstrual pictogram in selected cases (Fig, 5.1).

Of perhaps greater relevance is to determine the

impact of the condition on the patient's lifestyle and

quality of life. For example, the patient whose menor￾rhagia is so severe that she does not leave the house

during her period clearly has a much greater problem

(and may wish to pursue treatment further) than one

to whom menorrhagia is a minor inconvenience.

Is it relevant to determine the precise

amount of menstrual loss in women

complaining of menorrhagia?

This vexed question arises from the finding that only

50 per cent of women who complain of heavy periods

actually have a blood loss that would fulfill Ihe medical

definition of nienorrhagia. There is no single correct

answer to this question and, as is often the case in

medicine, each patient needs to be considered in the

light of her own circumstances. The rationale for any

investigation should be: 'Is this going to change the

treatment I prescribe for this patient?'. In general,

demonstration of the amount of blood lost during each

period will not change the treatment plan. Since it is the

patient's perception of loss that is important, treatmeni

may be appropriate for ali women, regardless of the

actual amount of blood loss. There are a few exceptions

to this rule, and there is a small proportion of women

(often young at the beginning of their reproductive life)

for whom the demonstration that their blood loss is in

fact 'normal' may be sufficient to reassure them and make

further Ireatmeni unnecessary

It Is also important to determine the duration of

the current problem, and any other symptoms or fac￾tors of potential importance. The following symp￾toms should be enquired about specifically, as they

may suggest a diagnosis other lhan PUB: irregular,

intermenstrual or postcoital bleeding, a sudden

change in symptoms, dyspareunia, pelvic pain or

premenstrual pain, and excessive bleeding from

other sites or in other situations (e.g. after tooth

extraction).

Clinical examination

Unless specific factors in the history alert the clinician

to the presence of organic disease, clinical exam￾ination of women presenting with menorrhagia

usually tails to reveal any significant signs. Despite this,

it is important to perform a physical examination,

including an abdominal and bimanual pelvic exam￾ination, in all women complaining of menorrhagia,

A cervical smear should he performed if one

is due.

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Menorrhagia 45

- the precise

in women

me finding that only

plain of heavy periods

nwtd fulfill the medical

•is no single correct

s often the case in

6e considered in the

The rationale for any

joing to change the

Sent?'. In general,

Mood lost during each

wit plan. Since it is the

is important, treatment

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ye are a few exceptions

proportion of women

their reproductive life)

t their blood toss is in

> reassure them and make

ermine the duration of

other symptoms or fac￾L The following syrnp￾out specifically, as they

er than DUB: irregular,

il bleeding, a sudden

ireunia, pelvic pain or

xessive bleeding from

itions (e.g. after tooth

listory alert the clinician

disease, clinical exam￾ing with menorrhagia

Scant signs, Pespite this,

i physical examination,

bimanual pelvic exam￾aining of menorrhagia.

be performed if one

Tampon

Clots

Flooding

Towel

Clots

Flooding

3 4 6 7

5.1 Menstmal pictogram.