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JPOG Editorial Nov Dec qxd


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									                                      •      G Y N A E C O L O G Y                             •

                  How To Treat Menstrual Disorders
                                                                            Cindy Farquhar, MBChB, MD, DipObst, MRCOG, FRANZCOG

        n this article, the causes and           intervals between menstrual periods         much of this section uses informa-
        treatment of heavy menstrual             is common in puberty and as women           tion contained in that guideline
        bleeding, painful periods, and           near the menopause. Anovulatory             (http://www.nzgg.org.nz/library/
        irregular or absent menses are           menorrhagia may also be present             gl_complete/gynae_hmb/index.cfm).
  discussed.                                     in women with polycystic ovaries
                                                 who often have irregular and                Aetiology
  MENORRHAGIA                                    heavy menses.                               Differential diagnoses of heavy
                                                     A Guideline for the management          menstrual bleeding that should be
  Menorrhagia is defined as heavy                of heavy menstrual bleeding was             considered include uterine pathology
  menstrual bleeding. The term ‘dys-             published in 1998 by the New                such as fibroids and hyperplastic
  functional uterine bleeding’ refers            Zealand Guidelines Group and                endometrium, complications of early
  to menorrhagia where no obvious
  pathology is present. Although
  menorrhagia is not usually life
  threatening, it can cause disruption
  and discomfort for many women.
     Over a 4-month period in the
  UK, one-third of women patients
  consulted their family doctor
  about their heavy periods. In New
  Zealand, it accounts for 10% of all
  specialist referrals from GPs. It
  may occur at any time between
  puberty and the menopause and is
  described as either ovulatory or
     A history of heavy menstrual
  bleeding with regular menstrual
  cycles is usually associated with
  ovulation whereas an anovulatory                 Figure 1. An ultrasound scan of thickened endometrium.
  pattern of bleeding with erratic

JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002                                                                     39
     H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                        •   GYNAECOLOGY                   •

     pregnancy such as miscarriage, carci-       presenting with excessive blood
     noma of the cervix and endometrium          loss, as many as 50% were losing
     (rarely), and exogenous hormones            amounts within the normal range.
     taken for menopausal symptoms.              The amount of bleeding is more
         Fibroids are present in about           likely to be excessive if hourly pad
     40% of women with menorrhagia,              and tampon changes are necessary
     although they are probably only             or sleep is disturbed by flooding.
     responsible for menorrhagia when                Neoplastic causes of bleeding
                                                                                               Figure 2. Taking a pipelle sample.
     they cause an enlargement of the            are highly unlikely in anovula-
     endometrial cavity or when they             tory menorrhagia associated with
     are submucous fibroids. In rare             puberty and, provided pregnancy             the possibility of fibroids and to
     cases, disorders of coagulation             has been excluded, therapy can be           exclude hyperplastic endometrium.
     may be present.                             commenced without the need for              (Figure 1)
         In many women, no obvious               vaginal examination or endometrial              Endometrial sampling to exclude
     cause is found for heavy menstrual          sampling. In all other women                neoplastic causes is usually restricted
     bleeding. Specialist referral is recom-     presenting with heavy menstrual             to those women at increased risk of
     mended if the Hb is very low, the           bleeding, a pelvic examination,             endometrial hyperplasia, such as
     uterus is greater than 12 weeks in          including a cervical smear, should          women over the age of 45 years or
     size or if the menstrual cycles are         be performed. Anaemia should be             those who weigh more than 90 kg.
     irregular.                                  excluded by a full blood count; it is       If endometrial thickness is greater
                                                 also an indication of the severity of       than 12 mm on ultrasound exami-
     Diagnosis and Investigations                the menstrual blood loss. Women             nation, an endometrial sample
     Subjective assessment by a woman            with Hb <120 g/L are more likely            should be taken. The least invasive
     regarding the amount of blood               to have blood loss >80 ml/cycle             technique of sampling is a pipelle
     loss can be misleading; studies             than women with a normal Hb.                sample. (Figure 2) Dilatation and
     have shown, when menstrual blood            An ultrasound scan is only indi-            curettage are only indicated when
     loss was quantified among women             cated if there is concern about             other sampling techniques fail.

        Table 1. Effective Medical Management of Menorrhagia

        Options                                  Dosages                            Reduction in Menstrual Blood Loss (%)
        • NSAIDs
          Mefenamic acid                         250-500 mg tid                     25-45
          Naproxen                               250 mg qid                         25-45
          Diclofenac                             75 mg bid                          25-35
        • Antifibrinolytic agents
          Tranexamic acid                        1 g tid/qid                        47
        • Combined OC pill                       30 µg EE + desogestrol             43
        • Danazol                                200 mg/day                         50
        • Levonorgestrel IUD                     20 µg/day                          86

40                                                                        JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002
  H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                                     •   GYNAECOLOGY                     •

  Hysteroscopy is indicated when
  intrauterine pathology, such as polyps
  or fibroids, is suspected. (Figure 3)                         Women reporting with heavy menstrual bleeding
                                                                   50% of women have menstrual blood loss >80 ml/cycle

  Medical Management
                                                                    Full menstrual history • Examination • Full blood count
  There are many effective options
  for the medical management of
                                                            Yes      Prolonged
  menorrhagia (Table 1), but the                                  irregular cycles
  symptoms often return once therapy                                      No
  is stopped and long term therapy                                  Abnormal
                                                       Refer Yes
  may be necessary.                                                exam uterine
                                                                 size >12 weeks
  NSAIDs                                                                                      mild or              treat
                                                       severe                                moderate
                                                                     Anaemic                                     anaemia
  Endometrial prostaglandins are                      <80 g/L                              (80 –115 g/L)
  elevated when menstruation is exces-                                    No
  sive. NSAIDs reduce prostaglandin                                                     low
  levels by inhibiting the enzyme                          Assess risk of              risk    Unexplained               Offer medical
                                                           endometrial hyperplasia          heavy menstrual                 therapy
  cyclo-oxygenase. Randomized con-                          • bodyweight=90 kg
                                                                                      < 2%       bleeding
                                                                                      have     90% of women
  trolled trials have consistently                          • age=45 years
  shown that NSAIDs decrease                                • other risk factors   endometrial                       • levonorgestrel
                                                                                                                     intrauterine system
  menstrual blood loss by between
                                                                                                                     • tranexamic acid
  30 and 40%. Mefenamic acid,                                              > 8% have
                                                                                                                     • nonsteroidal anti-
  ibuprofen, naproxen and diclofenac                                                                                 inflammatory agents
                                                             Assess endometrium                       normal
  have all been shown to be effective.                                                                               • norethisterone
                                                              • transvaginal ultra-                endometrium
                                                                                                                     long course
      NSAIDs are also helpful for                             sound (TVS) or
                                                                                                                     • OC pill
  women who have dysmenorrhoea                                • endometrial biopsy if
                                                                                                                     • danazol
                                                              endometrium=12 mm
  and up to 70% of women experience                           or if TVS not available                                if one medical therapy
                                                                                                                     fails, others can be used
  significant relief of pain. The com-
  mon side effects reported are
  headaches and gastrointestinal
  disturbances, including dyspepsia,                                Hyperplastic                                 success?
                                                                  endometrium or
  nausea, vomiting and diarrhoea.                                    carcinoma
  These disturbances can be avoided
  by taking the medication with                                                                         No                             Yes
  food and are unlikely to occur if
                                                                                           Refer to specialist for
  taken for a short time or inter-                                                         hysteroscopic evalua-         Continue medical
                                                                  Refer specialist
  mittently. Women with a previous                                                         tion and consideration        therapy
                                                                                           for surgery
  history of gastrointestinal ulcera-
  tion or a history of bronchospasm
  with aspirin should not be given                 Figure 3. Algorithm for treating women reporting with heavy menstrual bleeding.

JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002                                                                                      41
     H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                          •   GYNAECOLOGY                   •

                                                                                               pill has the additional advantages
                                             Case Study: History of Heavy                      of reducing dysmenorrhoea and
                                             Bleeding                                          providing contraception.

                                             Presentation: A 47-year-old woman pre-            Danazol
                                             sented with a 6-month history of increas-         Danazol is a synthetic steroid
                                             ingly prolonged and heavy menstrual
                                                                                               with mild androgenic properties. It
                                             periods. There was no dysmenorrhoea.
                                             Her cycle was 14 days of bleeding every           causes atrophy of the endometrium
                                             30 days.                                          and is therefore useful in the
                                             Examination/investigations: An examina-           treatment of dysfunctional uterine
                                             tion was undertaken and the pelvic organs         bleeding. Although it is an effective
                                             were normal. A cervical smear was taken
                                                                                               agent in reducing menstrual blood
                                             and the cervix looked normal. The FBC
                                             was normal. An ultrasound scan demon-             loss, adverse side effects (even at
       Ultrasound scan of endometrial
                                             strated a normal uterus with no fibroids          lower doses) such as weight gain,
                                             but a prominent endometrial echo sug-             depression, acne and headaches,
                                             gested an endometrial polyp 11 x 10 mm.           limit its usefulness.
        Treatment: Hysteroscopy, dilatator and curettage were performed under gen-
        eral anaesthesia. An endometrial polyp was found and removed with polyp for-
        ceps. Histology found a benign endometrial polyp.                                      Progestogens
        Outcome: At 3 months’ follow-up, her menstrual periods had returned to their           Progestogen therapy given in the
        previous pattern. However, 12 months later, the patient returned with increas-         luteal phase has been widely used
        ingly heavy periods – although only for 8 days a month. An ultrasound scan of          in the treatment of dysfunctional
        the endometrial echo was normal (7 mm). Tranexamic acid (1 g three times a
                                                                                               uterine bleeding for many years.
        day) was prescribed and the periods became more manageable.
                                                                                               However, randomized controlled
                                                                                               trials have shown it to be repeatedly
     Antifibrinolytic Agents                     19 years, this was shown to be no             ineffective in ovulatory menorrhagia.
     Treatment with tranexamic acid,             higher than would be expected in              One study has even shown that it
     an antifibrinolytic agent, results in       the normal population. Although it            causes a 20% increase in menstrual
     decreases in menstrual blood loss           is currently restricted in New                blood loss. It can be used to manage
     of 30 to 50%. The mode of action            Zealand to specialist prescribing, it         irregular anovulatory cycles as it
     involves depression of the fibri-           is hoped this will change. The                will induce a regular withdrawal
     nolytic activity of peripheral blood        dosage is 1 g three or four times a           bleed when given for 7 days of each
     through the inhibition of plasmino-         day on the days of heavy bleeding.            calendar month. Once menstrua-
     gen activation. Nonspecific side                                                          tion commences, other therapies
     effects are reported in approximately       Oral Contraceptives                           may be given such as NSAIDs or
     one-third of women and include              The combined OC pill is useful                tranexamic acid.
     nausea and leg cramps. There is no          in reducing menstrual blood loss                  Although progestogen therapy
     impact on dysmenorrhoea.                    and establishing regular cycles,              no longer has a place in the main-
         There have been two cases of            but the reduction in menstrual                tenance therapy of regular heavy
     intracranial thrombosis reported in         blood loss is less certain, as only           periods, it still has an important
     Finland, but in a large epidemio-           one randomized clinical trial has             role in emergency suppression of a
     logical population-based study over         addressed this. Use of the OC                 heavy, extended menstrual bleeding

42                                                                          JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002
  H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                     •   GYNAECOLOGY              •

  episode. This is achieved by giv-              have been shown to reduce men-
  ing norethisterone (15 mg/day)                 strual blood loss by almost 90% in
  or medroxyprogesterone acetate                 women with menorrhagia after the
  (30 mg/day) for 3 to 4 weeks. The              first few months of use. They also
  dosage can be decreased once bleed-            provide very effective contracep-
  ing has ceased. Bleeding should                tion with a low pregnancy rate
  stop in the first week but if it does          (PEARL index <1) and are effective
  not, the dosage can be increased.              in reducing dysmenorrhoea. The           Figure 5. Thermal ablation
  Once the patient has been free                 reported infection rate is lower
  of bleeding for 3 to 4 weeks,                  than that reported with other
  progestogen can be stopped and a               IUDs. In New Zealand, they are         term follow-up studies of effective-
  withdrawal bleed should occur.                 not funded unless provided within      ness are awaited. A US trial com-
  Maintenance therapy can then be                a public hospital.                     paring roller ball ablation with
  instituted.                                                                           balloon therapy ablation has
      Another regimen is to give                 Surgical Management                    shown similar results for amenor-
  medroxyprogesterone acetate                    There are two main surgical            rhoea at 6 months. About 10 to
  10 mg/day initially and increase               options for menorrhagia:               15% of women who undergo
  the dosage each day until the                      • endometrial destruction by       ablation continue to have heavy
  bleeding has stopped.                          either laser or resectoscope, roller   menstrual periods but the remain-
                                                 ball ablation or thermal balloon       der either have hypomenorrhoea
  Levonorgestrel IUD                             ablation;                              (35%) or amenorrhoea (50%).
  Medicated intrauterine devices                     • hysterectomy.                       At 4 years of follow-up, 25%
  (Figure 4) which release levo-                                                        of women who have had ablation
  norgestrel in a controlled manner              Endometrial Destruction                by resectoscope or roller ball will
                                                 The hysteroscopic methods of laser,    have had a hysterectomy either for
                                                 resectoscope or rollerball have        continuing heavy menstrual bleed-
                                                 become well established over the       ing or cyclical pelvic pain. Women
                                                 past 5 years as methods of removing    who have endometrial ablation
                                                 endometrium. The procedure takes       need HRT with both oestrogen and
                                                 30 to 60 minutes and is usually        progestogen when they reach the
                                                 done under general anaesthesia.        menopause.
                                                 Complications of haemorrhage,
                                                 perforation and fluid overload         Hysterectomy
                                                 have been reported.                    There are three major techniques for
                                                    The thermal balloon ablation        performing a hysterectomy: vaginal,
                                                 system is relatively new in New        total abdominal and laparoscopi-
                                                 Zealand. It is simple to use and       cally assisted. Providing the uterus
                                                 avoids major complications that        is not larger than 12 weeks, the
    Figure 4. Photo of levonorgestrel
                                                 accompany other techniques. (Figure    majority of hysterectomies should be
    IUD.                                         5) It can also be performed under      performed through the vaginal route.
                                                 local anaesthesia. However, long       The abdominal route is restricted

JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002                                                                43
     H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                         •   GYNAECOLOGY                   •

     to those women with severe pelvic           AMENORRHOEA                                      Thyroid or adrenal dysfunc-
     disease such as endometriosis or                                                         tion or increased production of
     large fibroids. The laparoscopic route      Although the absence of menstrua-            androgens or prolactin may
     is particularly suited to those women       tion may be welcome, it can indicate         interfere with the menstrual cycle.
     who have no descent of the cervix           severe disturbance of the hypothala-         Pregnancy must always be excluded
     such as nulliparous women and those         mic-pituitary axis. Amenorrhoea is           in any woman complaining of
     with moderate endometriosis. Some           defined as an absence of menstrua-           amenorrhoea.
     70% of hysterectomies can be per-           tion for longer than 3 months.
     formed through the vaginal route.           A woman with irregular periods               Diagnosis
         It is possible to remove ovaries        which occur more frequently than             The ‘amenorrhoea sieve’ can be
     via the vaginal route. Total abdomi-        3 months is described as having              used to filter possible diagnoses
     nal hysterectomy is usually necessary       oligomenorrhoea. Primary amen-               when assessing a patient with
     in 15% of women and the remain-             orrhoea is defined as the absence            amenorrhoea:
     der can be performed laparoscopi-           of periods up to the age of 16                  • uterus and outflow tract;
     cally. The cervix is usually removed        after reaching 50 kg, whereas                   • the ovary;
     at hysterectomy although some               secondary amenorrhoea is the                    • pituitary and hypothalamic
     women may choose to conserve it.            absence of periods after sponta-             centres;
         Women who decide to keep the            neous menarche.                                 • inappropriate or excessive
     cervix require either an abdominal              An understanding of the                  production of thyroxine, prolactin
     hysterectomy or CASH procedure              physiology of menstruation is                or androgen;
     (classical Semm hysterectomy using          necessary to understand the causes              • pregnancy.
     laparoscopic techniques). Women             of amenorrhoea and oligomenor-
     who retain their cervix need to             rhoea. Menstruation depends on               Disorders of the Uterus or
     continue to have cervical screening.        oestrogen production from the                Outflow Tract (Rare)
     Over 95% of women are satisfied             ovary, the presence of a responsive          These are commonly anatomical
     with the operation of hysterectomy          endometrium, and a patent out-               anomalies and include the following:
     but it does involve a 4- to 6-week          flow tract. (Figure 6)                           Paramesonephric duct anomalies.
     convalescent period and in a few                                                         Failure of complete development
     per cent of women, there is dissatis-                                                    of the genital tract can result in
     faction because of new or ongoing                                                        primary amenorrhoea in the
     symptoms.                                                                                presence of normal secondary sex
         Although it is not clear if                                                          characteristics. If any endometrium
     removal of the ovaries prevents                                                          is present, the patient will develop
     the recurrence of endometriosis,                                                         haematocolpos or haematometra
     consideration should be given to                                                         and cyclical abdominal pain.
     removing both ovaries at the time                                                            Androgen insensitivity (testicular
     of hysterectomy for women with                                                           feminization). These patients present
     endometriosis or pelvic pain other                                                       at puberty with primary amenor-
     than menstrual pain. If the ovaries                                                      rhoea and lack of sexual hair (no
                                                   Figure 6. Physiological requirements
     are removed, HRT is given which               of menstruation.                           androgen receptors), but do have
     is usually oestrogen alone.                                                              breast development due to the

44                                                                         JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002
  H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                        •   GYNAECOLOGY                  •

  action of oestrogen secreted by the                Hypothalamus. Hypothalamic
  testes. They have a male karyotype             disorders are the most common
  and are sterile but otherwise lead a           cause of secondary amenorrhoea and
  normal female life. Disclosure of              include: weight loss-related amen-
  the karyotypic gender is a difficult           orrhoea in athletes, dancers and in
  issue, as is gonadectomy.                      anorexic disorders; treatment with
      Endometrial destruction. Curettage         phenothiazines which interfere with
                                                                                             Figure 7. Normal ovary (left) and
  of the uterus may very rarely totally          hypothalamic-pituitary function; and
                                                                                             polycystic ovary (right).
  denude the uterus of endometrium.              rare destructive hypothalamic lesions.
  Intrauterine adhesions form and                    Pituitary. Pituitary adenomas
  amenorrhoea follows.                           produce excess prolactin which                Thyroid disease. Only gross dis-
                                                 interferes with ovarian function.         turbance of thyroid function will
  Ovarian Disorders (Rare)                       Galactorrhoea may be present.             interfere with menstruation.
  Raised gonadotropin levels are the             Rarely, anterior pituitary failure
  hallmark of ovarian absence or                 occurs following severe postpar-          Management
  failure.                                       tum haemorrhage.                          Treatment will depend on the
      Gonadal agenesis. The gonads                                                         cause of amenorrhoea and will
  fail to develop and no secondary               Inappropriate or Excessive                need to take into account a number
  sex characteristics appear. The                Hormone Production                        of factors including the patient’s
  karyotype is 46XX.                             The feedback mechanisms are               age, desire for fertility and diagno-
      Gonadal dysgenesis. Turner’s               deranged.                                 sis. There is no need to induce
  syndrome (46XO, mosaics) is the                    Polycystic ovarian syndrome.          menstruation prior to evaluation;
  most common of these disorders.                This disorder of the hypothalamic-        it may confuse the clinical picture.
  Features include short stature,                pituitary-ovarian axis is characterized
  webbed neck, shield chest and                  by raised LH and testosterone levels      Weight Related Amenorrhoea
  increased carrying angle. Some                 in 50% of cases. The ovaries are          This is usually treated by psychother-
  functional ovarian tissue may be               enlarged by a peripheral ring of          apy and use of antidepressants such
  present leading to a degree of                 follicles and stromal hypertrophy.        as fluoxetine. Menstruation will
  secondary sex development.                     Oligomenorrhoea (less commonly,           usually commence spontaneously
      Premature ovarian failure. The             amenorrhoea) and hirsutism occur.         once a BMI of 19 is achieved.
  cause of ovarian failure before the            The common symptoms of andro-             Excessive exercise programmes
  age of 40 years is usually unknown             gen excess, hirsutism and acne are        need to be reduced to under 3
  but it may be an autoimmune                    most frequently seen in the poly-         hours a week. Where the patient
  disorder. FSH levels are consistently          cystic ovarian syndrome. BMI >30          cannot gain weight, oestrogen
  raised.                                        usually worsens the problem due           should be given as either HRT or
                                                 to excess androgen production in          the combined OC pill. This will
  Disorders of the Hypothalamic-                 adipose tissue. (Figure 7)                protect the skeleton from stress
  Pituitary Axis                                     Rare androgen secreting tumours       fractures or osteoporosis in the
  The pelvic organs are normal and               of the ovary or adrenal. Adrenal          future, a problem that may occur
  the fault lies within the hypothala-           hyperplasia and Cushing’s syn-            in athletes with low bone mineral
  mus or pituitary gland.                        drome lead to amenorrhoea.                density.

JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002                                                                      45
     H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                          •   GYNAECOLOGY                   •

                                                                                               Polycystic Ovarian Syndrome
                                                                                               Regular withdrawal bleeds can be
       Drug Therapy
                                                                                               induced by using luteal phase
       NSAIDs                                   Medroxyprogesterone                            progestogen such as medroxy-
       For menorrhagia, dysmenorrhoea           • Provera                                      progesterone acetate or norethis-
       Diclofenac sodium                        Norethisterone                                 terone (days 19 to 26) or the oral
       • Voltaren, Voltaren SR                  • Noriday 28                                   contraceptive pill.
       • Diclax, Diclax SR                      • Primolut N                                        If fertility is desired and anovula-
                                                                                               tion is established by a low day-21
       Mefenamic acid                           Danazol
       • Ponstan                                For menorrhagia/dysmenorrhoea                  serum progesterone, then ovula-
                                                (use for several months then review)           tion induction is indicated with
       Naproxen                                 • Danocrine
                                                                                               clomiphene citrate as the first choice.
       • Naprosyn, Naprosyn enteric,
         Naprosyn SR                            Bromocriptine Mesylate                         It is important to ensure the patient
       • Naxen                                  For amenorrhoea                                has a BMI <32 as clomiphene is
       • Noflam, Noflam EC                      • Parlodel                                     more likely to be successful. The
       Tiaprofenic acid                         Clomiphene Citrate                             role of metformin in helping with
       • Surgam                                 For polycystic ovarian syndrome                weight reduction and return of
       • Surgam SA                              • Clomid                                       ovulatory cycles is as yet unproven
       Combined Oral Contraceptive Pill         Hormone Replacement Therapy                    and randomized controlled trials
       For menorrhagia, dysmenorrhoea,          For premature ovarian failure (if              are awaited. The usual starting dose
       polycystic ovarian syndrome.             ovulation not required). If the patient        is 25 to 50 mg of clomiphene citrate
       Different combinations in relation to    has intact uterus and is less than
                                                                                               from days 2 to 6 of the cycle. Eighty
       different needs, eg. lowest dose that    2 years from her last menstrual
       would be effective for suppression of    period (LMP), use a sequential                 per cent of women will ovulate
       ovulation, especially for young women.   oestrogen/progestogen combination              with clomiphene citrate in increas-
       Mercilon is the only one available in    to induce a monthly withdrawal
                                                                                               ing doses up to 150 mg/cycle.
       New Zealand with 20 µg of oestrogen      bleed. If intact uterus but more than
       – all others have 30 µg or more.         2 years since LMP, then continuous                  Women who fail to ovulate with
       Diane-35 has the anti-androgen agent     oestrogen/progestogen preparations             clomiphene citrate can be offered
       for acne, hirsutism, etc.                can be prescribed. It seems likely             either gonadotropin therapy (given
                                                HRT can be used indefinitely, but
       Levonorgestrel IUD                       certainly for 5 years after                    either by IM or SC injections daily
       For menorrhagia                          menopause (ie. LMP), if there are no           in the follicular phase) or the newer
       • Mirena                                 contraindications to its use in the            treatment of laparoscopic ovarian
                                                first place.
       Tranexamic Acid                                                                         drilling.
       For menorrhagia                                                                              Laparoscopic ovarian drilling
       • Cyklokapron                                                                           probably works by destroying some
                                                                                               of the androgen-producing cells
       For irregular cycles – in order to                                                      within the stroma, and overall the
       induce regular withdrawal bleeding                                                      ovarian volume decreases. The cost
       (taken cyclically days 19 to 26 if
                                                                                               of gonadotropin therapy varies from
       contraception not required) or for
       emergency suppression of prolonged                                                      NZ$1000–4000 per cycle and is
       or heavy menstruation.                                                                  therefore restricted to women who
                                                                                               are resistant to clomiphene citrate.

46                                                                          JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002
  H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                         •   GYNAECOLOGY                •

                                                                                            sequential preparations, continuous
      Case Study: Magazine Self-Diagnosis                                                   preparations can also be given.
                                                                                                Other conditions causing
      Presentation: A 36-year-old woman reads in a popular women’s magazine about           oligomenorrhoea are rare.
      a syndrome where women have irregular periods and problems of excessive facial
      hair. She consults her doctor telling her that she hasn’t had a period for 5 years.
      Prior to this, she had had three to four periods a year since menarche at age
      14. She had an increasing facial hair problem and spent a considerable amount
      of money having weekly electrolysis. However, she still had a lot of facial hair.     Dysmenorrhoea, or painful men-
      Examination/investigations: Her hormone results were: LH 17.6 IU/L; FSH               strual cramps, is a common and
      8.4 IU/L; testosterone 2.4 mmol/L; SHBG 36; free testosterone 56; prolactin           often debilitating problem that can
      251 mmol/L.
                                                                                            cause a major disruption to a
      An ultrasound scan confirmed the suspected diagnosis of polycystic ovaries
      and the endometrial thickness was 10 mm.                                              woman’s life. Approximately 70%
      Treatment: A withdrawal period was induced with Provera 5 mg for 5 days and           of adolescents experience dysmen-
      the patient was commenced on an anti-androgen, cyproterone acetate, for 10            orrhoea and of these about 10%
      days a month in conjunction with an oral contraceptive pill. Fertility was not        lose significant time from school or
      desired. Follow-up was arranged at 3/12. The patient was warned that no
                                                                                            work because of incapacitating
      improvement was likely for at least 3 months.
                                                                                            pain on a monthly basis. There are
                                                                                            two categories of dysmenorrhoea
      Where hirsutism is present,                 the pituitary are indicated. The          described; primary dysmenorrhoea
  management will differ. Anti-andro-             patient may initially experience some     occurring in the absence of pelvic
  gens are effective treatment for hir-           nausea and vomiting and therefore         disease and typically in adoles-
  sutism; their mechanism of action is            the initial dosages of bromocrip-         cents, and secondary dysmenor-
  to suppress ovarian androgen pro-               tine are low at 2.5 mg bid and then       rhoea, where identifiable pelvic
  duction and to block the androgen               gradually increased. Surgery is rarely    pathology is usually present, most
  receptors in the hair follicles. Acne           indicated for hyperprolactinaemia.        often arising as a new problem for
  starts to improve within 6 weeks of                                                       a woman in her 30s and 40s.
  therapy. Hirsutism usually takes 4              Ovarian Failure                               Symptoms may include cramp-
  to 6 months to improve because of               Premature ovarian failure is indi-        ing, lower abdominal pain, pain that
  the length of time of the hair growth           cated by persistently elevated FSH        radiates to the back and upper
  cycle, and treatment is usually neces-          levels (>20 mmol/L). If fertility is      thigh, nausea or vomiting, diar-
  sary for 12 months. A contracep-                desired, then referral to a fertility     rhoea, headache and fatigue. Pain
  tive pill containing 35 µg ethinyl              clinic to discuss ovum donation pro-      can occur several hours before
  estradiol and cyproterone acetate               grammes is appropriate. HRT with          bleeding starts. It is usually most
  can be used as maintenance therapy.             both oestrogen and progestogen            severe on the first day of bleeding.
                                                  should be commenced to treat the          Primary dysmenorrhoea typically
  Hyperprolactinaemia                             short term problem and avoid the          only starts on the first day of bleed-
  This is managed by lowering pro-                long term consequences of prema-          ing and is not prolonged.
  lactin levels with either bromocrip-            ture menopause such as osteoporo-
  tine or cabergoline. When repeated              sis. Although most women with             Aetiology and Diagnosis
  levels of prolactin are greater than            premature ovarian failure prefer          In women under the age of 20, period
  1000, then a CT scan or MRI of                  to have regular periods by using          pains are unlikely to be associated

JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002                                                                      47
     H O W T O T R E AT M E N S T R U A L D I S O R D E R S                                        •    GYNAECOLOGY                       •

     with pathology. Studies indicate            advantage of reducing the men-              therapy. If symptoms persist follow-
     that many women with primary                strual blood flow in women with             ing surgical therapy, medical therapy
     dysmenorrhoea have increased                heavy menstrual bleeding. They              can be started.
     abnormal uterine activity which is          are usually started with the onset              First choice of medical therapy
     secondary to increased release of           of menstrual bleeding.                      should be the oral contraceptive
     endometrial prostaglandins at the               Contraindications to their use          pill, medroxyprogesterone acetate
     time of menstruation. This abnormal         include a past history of gastroin-         (depot or oral), gestinone or danazol
     activity leads to uterine ischaemia.        testinal ulcers and bronchospastic          (limited to 6 months’ use). If these
     In secondary dysmenorrhoea, the             reaction to aspirin or aspirin-like         medications are unsuccessful at con-
     pain typically begins several days          drugs.                                      trolling painful symptoms, then the
     before the onset of menstruation                                                        more expensive gonadotropin-
     and other symptoms such as dys-             Oral Contraceptives                         releasing hormone agonists can be
     pareunia and menorrhagia may be             Oral contraceptive pills reduce             given for a maximum of 6 months.
     present.                                    the pain of primary dysmenor-               Hot flushes are almost universal
         The aetiology of secondary dys-         rhoea by reducing menstrual fluid           (98%) and in some women it may
     menorrhoea includes endometriosis,          prostaglandins as a result of an            be necessary to ‘add back’ oestro-
     the presence of an IUD and pelvic           overall decrease in menstrual blood         gen. Prolonged use beyond 6 months
     congestion. Specialist referral for         flow. The endometrial atrophy               should be limited owing to negative
     diagnostic laparoscopy should be            results in less endometrial shedding        impact on bone mineral density.
     considered in women who present             and bleeding. They do not suppress              Pelvic congestion can be visualized
     with dysmenorrhoea for the first            prostaglandin production through            at laparoscopy in the absence of
     time in their 30s who do not                the enzymatic pathway. They are             other pathology. Typical symptoms
     respond to simple measures such as          very effective and 80% of women             are secondary dysmenorrhoea,
     anti-inflammatory drugs or the              treated with oral contraceptive             pelvic pain symptoms clustered in
     combined oral contraceptive pill.           pills will have a significant reduc-        the luteal phase, dyspareunia and
                                                 tion in pain.                               postcoital ache. Treatment is usually
     Management                                      A trial of therapy with oral con-       by suppressing ovulation with
     Management of primary dysmen-               traceptive pills and anti-inflamma-         medroxyprogesterone acetate.
     orrhoea is centred on two therapies:        tory medication should be given to
     NSAIDs and the combined OC pill.            those women with primary dysmen-
                                                 orrhoea and those with secondary
     NSAIDs                                      dysmenorrhoea where pelvic exami-
     NSAIDs are used only for the days           nation appears to be normal prior
     of the menstrual cycle on which             to specialist referral.
     symptoms occur. Clinical trials have            Where endometriosis is found,
     shown efficacy with most NSAIDs             then laparoscopic ablation or excision
     including mefenamic acid, ibupro-           is often undertaken at the time of          About the Author
     fen, naproxen and diclofenac.               the diagnostic laparoscopy. This has
                                                                                             Dr Farquhar is an Associate Professor in
     Complete to moderate pain relief            been shown to be more effective than        Reproductive Medicine, Department of Obstetrics
                                                                                             and Gynaecology, School of Medicine, University
     is achieved in 70% of patients.             no therapy although no trials have          of Auckland, National Women’s Hospital, New
     These agents will have the added            compared surgery with medical               Zealand.

48                                                                        JOURNAL OF PAEDIATRICS, OBSTETRICS AND GYNAECOLOGY NOV/DEC 2002

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