Menstrual Disorders | Medical Science Optional Notes for UPSC PDF Download

Abnormal Uterine Bleeding/Dysfunctional Uterine Bleeding

'Dysfunctional uterine bleeding' (DUB) was coined to describe abnormal heavy menstrual bleeding when no structural genital tract abnormality or general cause was detected, in a woman of reproductive age in the absence of pregnancy. This condition is due to several causes that make the standard methods of investigations and management inconsistent and difficult.

Abnormal uterine bleeding (AUB) has replaced the term 'dysfunctional uterine bleeding' in a woman of reproductive age in the absence of pregnancy.

Differential Diagnosis (PALMS COEIN Classification of AUB)

Investigations

Contrary to the PALM group, the COEIN group cannot be detected by imaging and histopathology.

• Complete haemogram
• Bleeding time and clotting time
• Thyroid profile
• Pelvic sonography/sonosalpingography
• Diagnostic hysteroscopy
• Diagnostic laparoscopy
• Endometrial study by ultrasound and curettage
• Pelvic angiography 

Management

• Proper diet
• Adequate rest during menses
• Manage Anemia (Oral hematinics)
• Vitamins and protein supplements
• Maintain a menstrual calendar noting duration and extent of blood loss.

Metropathia Haemorrhagica (Schroeder's disease)

• Specialized form of Anovulatory AUB
• Seen in age group 40-45 years
• Symptoms-Amenorrhea of 8-10 weeks followed by painless vaginal bleeding
• The uterus is slightly bulky (6-8 week size)

Histopathology

• U niformly enlarged uterus, myohyperplasia with uterine wall measuring up to 25 mm.
• Ovaries are cystic (No corpus luteum)

ENDOMETRIUM

• Thick polypoidal endometrium with thin slender polyps
• CYSTIC GLANDULAR HYPERPLASIA (SWISS CHEESE PATTERN)-Characteristic endometrial feature
• Superficial necrosis of endometrium
• Absence of secretory endometrium (Absence of corkscrew glands)

Investigations

• Endometrial study (Currettege/Aspiration/Hysteroscopic biopsy)
• Ultrasound to rule out pelvic organ disease
• Doppler ultrasound to study endometrial vascularity
• HSG/SSG
• MRI if needed
• General invedstigations-CBP/TFT/Coagulation profile

The treatment should be based on the age of the woman, her desire to retain fertility, previous treatment and severity of menorrhagia (Same table-management of AUB above)

Menopause

• Menopause is defined as the time of cessation of ovarian function resulting in permanent amenorrhoea.
• It takes 12 months of amenorrhoea to confirm that menopause has set in, and therefore it is a retrospective diagnosis.

Clinical Features (Signs and Symptoms)

Hormonal Replacement Therapy (HRT)-Menopause

• Osteoporosis is an incipient slowly progressing skeletal disorder characterized by micro architectural deterioration of bone mass resulting in increased fragility and predilection to fracture in the absence of significant trauma.
• Osteoporosis is defined as a condition in which there is a fall in bone mass exceeding 2.5 standard deviations (SD) below the mean for young adults. About 15% of elderly women suffer from osteoporosis and almost three times as many suffer from osteopenia (deficient bone mass).
• Oestrogen deficiency is the dominating factor contributing to osteoporosis in women. Additional contributing factors such as calcium and vitamin D deficiency also need consideration.

Prophylaxis of Osteoporosis

• Diet
• Plenty of calcium and vitamin D
• Postmenopausal women should consume 1200 mg of calcium per day (total of diet plus supplements)
• The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, and hard cheese, and green vegetables, such as kale and broccoli
• Experts recommend postmenopausal women consume 800 international units (20 micrograms) of vitamin D each day.
• Milk, salmon, orange juice, yogurt, and cereal are available with added vitamin D
• Smoking and alcohol-increases risk of osteoporosis
• Exercise may decrease fracture risk by improving bone mass in premenopausal women and helping to maintain bone density in women who have been through menopause. Most experts recommend exercising for at least 30 minutes three times per week.

Avoid medications that increase bone loss

• Glucocorticoids
• Heparin
• Antiepileptic drugs
• Aromatase inhibitors

DRUGS

• Oestrogen hormone therapy-ERT (hysterectomized)
• Oestrogen + progesterone (HRT)
• Tibolene
• Raloxifene
• Bisphosphonates for late osteoporosis
• Calcitonin- Calcitonin is a hormone produced by the thyroid gland that, together with PTH, helps to regulate calcium concentrations in the body. Its no longer used.
• Parathyroid- Parathyroid hormone (PTH) and parathyroid hormone-related protein (PTHrP) are unique osteoporosis drugs in that they are the only medications that work by stimulating bone formation

Hormonal Replacement Therapy (HRT)

HRT-Hormone Replacement Therapy is the cornerstone in the prophylaxis and treatment of osteoporosis

When to Start HRT?

It is observed that benefit of HRT lasts while the woman continues to take HRT, and the bone loss resumes once she stops taking drugs. Since the prolonged therapy beyond 8-10 years is not beneficial but perhaps harmful, most gynaecologists now follow-up the woman for osteopenia and prescribe HRT when osteopenia occurs.

Risks of HRT:

• Endometrial cancer
• Breast cancer
• Ovarian cancer
• Thromboembolism
• Lipid profile dysfunction
• Gall stones, liver dysfunction

Post menopausal bleeding

Vaginal bleeding occurring after 6 months of amenorrhoea in a menopausal women should be considered as post menopausal bleeding and investigated.

Causes

Post menopausal bleeding

Investigations

• Blood count and smear will reveal blood dyscrasia.
• Blood sugar levels.
• Cervical cytology for cervical lesion.
• Endometrial study.
• Sonosalpingography for endometrial polyp.
• Ultrasound—endometrial thickness of more than 4 mm indicates the need of endometrial biopsy.
• CA 125 serum levels.