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Petr Kepelka Menstrual cycle disorders

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Diagnosis

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MENSTRUATION Periodic desquamation of the endometrium The external hallmark of the menstrual cycle Just before menses the endometrium is infiltrated with leucocytes Prostaglandins are maximal in the endometrium just before menses Prostaglandins constriction of the spiral arterioles ischemia & desquamation Followed by arteriolar relaxation, bleeding & tissue breakdown

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NORMAL MENSTRUAL CYCLE The mean duration of the MC Mean 28 days (only 15% of ) Range 21-35 The average duration of the MC 3-8 days The normal estimated blood loss? Approximately 30 ml Ovulation occurs Usually day 14 34 hrs after the onset of mid-cycle LH surge

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Definition of normal menstruation Regularity Frequency - Cycle lenght Duration of menstrual flow Volume of menstrual flow

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Describing normal uterine bleeding Regularity of menstruation Regular Iregular Absent Frequency Frequent Normal Infrequent

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Describing normal uterine bleeding Duration of menstrual flow Prolonged Normal Shortened Volume of menstrual flow Heavy Normal Light

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Nomenclature for normal menstraution Abnormal uterine bleeding FeatureNormalAbnormality 1Abnormality 2 RegularityRegular 2;20d Iregular variation > 20d Absent FrequencyNormal q 24- 38d Frequent < 24d Infrequent >38d DurationNormal 4,5-8dProlonged > 8d Shortened

Myoma classification Submucosal0Pedunculated intracavitary 1>50% intracavitary 250% intracavitary Other3Contacts endometrium, 0% intracavitary 4Intramural 5Subserosal 50% intramural 6Subserosal

Oligomenorrhoe Oligomenorrhoe cycle > 35 days Therapy -No therapy (normoestrogenic disorders) Progestines during luteal phase of cycle (normoestrogenic disorders) Progestines+estrogenes (hypoestrogenic disorders) Induction of ovulation (infertility)

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Primary amenorrhoe Therapy - casual Progestines+estrogenes (hypoestrogenic disorders)

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Secondary amenorrhoe Therapy normoprolactinemic and normoestrogenic Progestogenes Ovulation induction

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Heavy or prolonged uterine bleeding Menoragia Hypermenorhea DUB =dysfunctional uterine bleeding AUB = abnormal uterine bleeding

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26 Dysfunctional uterine bleeding - therapy Observation DG Pharmacological Spont.normalization Recurrence D & C Failure - Surgical - Endometrial ablation/destruction / Hysterectomy

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Pharmacological therapy of DUB Hormonal Estrogens (E) Progestins (P) E/P Danazol GnRh - a SERM Non-hormonal Nonsteroidal antirevmatics Mefenamic acid Ethamsylate Antifibrinolytics EAC Tranexamic acid

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28 Pharmacological therapy of DUB Individual Age-specific Treatment outcome and side effects are unpredictable Side effects are common Economic efficiency Need for surgical treatment is often

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Estrogens CEE - 2.5 mg p.o. a 6 h. or 25 mg i.v. a 4 h. for 48 h. Progestins MPA 10 mg/d for 10-12 d. NES 10-15 mg/d 10 d. LNG-IUS 29 Pharmacological therapy of DUB

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E/P Combined orla contraception Acute DUB - 70-140 g/d Prevention usual pattern, long cycle pattern, continual Adolescent gynecology acute DUB Progesterone 10 mg/ Estradioldipropionate 2 mg i.m. 30 Pharmacological therapy of DUB

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Danazol 200-400 mg/d not available in Czech Republic GnRH agonists goserelin (Zoladex Depot 3,75 mg) tryptorelin (Decapeptyl Depot 4,12 mg, Dipherelin 4,39 mg) leuprorelin (Lucrin Depot 3,75 mg) 31 Pharmacological therapy of DUB

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Nonsteroidal antirevmatics Naproxen (Aleve tbl.220 mg, Apo-naproxen tbl. 250 mg, Nalgesin tbl. 270 mg) Mefenamic acid (Nimesulid tbl. 100 mg) Antifibrinolytics Tranexamic acid (Exacyl p.o. tbl. 500 mg, oral solution 10ml/1000 mg a venous injection 5 ml/500mg) 32 Pharmacological therapy of DUB

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Effectiveness of pharmacotherapy Hormonal Progestins - 21 day cycle 30-90% Combined oral contraception 43% Danazol 50-80% LNG IUS 74-97% DMPA 50-66% GnRH agonists >90% Non-hormonal Non-steroidal antirevmatics 20-50% ? Tranexamic acid 47- 54% Etamsylate 13%?

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Surgical therapy of DUB Endometrial ablation hysteroscopical Roller ball ablation (25-60%) Transcervical resection (26-40%) Laser ablation (37%) 34

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Surgical therapy of DUB Endometrial ablation non- hysteroscopical methods RFEA Radio Frequency Endometrial Ablation (41%) TBEA Thermal Balloon Endometrial Ablation (48%) MWEA Microwave Endometrial Ablation (61%) 35

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Surgical therapy of DUB Vaginal hysterectomy LAVH laparoscopically assisted vaginal hysterectomy Abdominal hysterectomy (minilaparotomy) 36

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Surgical therapy of DUB - controversies Dilatation+curettage Diagnostic procedure Endometrial - Resection/ablation Many costly methods Many failures selhn Hysterectomy Invazive Operational risks Expensive Suitable for women over 40 37

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Hypomenorrhoe Posttraumatic Aschermanns syndrome Therapy Hysteroskopy lysis of adhaesions IUD - estrogens

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Dysmenorrhea - therapy Secondary dysmenorrhoea causative Primary dysmenorrhoea combined hormonal contraception effectivity 90% Progestogens contraception long acting LNG-IUS Non-steroidal anti-inflammatory drugs (NSAIDs) 2-3 days before menstrual bleeding Continue to the 2.day of bleeding

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Premenstrual syndrome - therapy Diet regime restriction of coffein, alcohol, salt, glycids Aerobic exercise Psychological consultation

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Premenstrual syndrome - therapy Symptomatic treatment according to prevailing syndrome Combined oral contraception (drospirenon) Agnus castus Non-steroidal anti-inflammatory drugs SIRS - fluoxetin

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thank you for your attention