- Normal: 3 to 5 week cycle.
- Hormone regulation:
- GnRH → anterior pituitary releases FSH and LH. In first half of cycle, FSH predominates → ovarian follicles mature and release estrogen to induce endometrial proliferation. Mid-cycle LH surge → ovulation and formation of corpus luteum that secretes progesterone → compacts and matures the endometrium. If no pregnancy, progesterone drops off and menstruation occurs.
- Consider:
- PCOS, thyroid problems, whether the source of bleeding is elsewhere (vagina, rectum, cervix, etc), medications (anticoagulants, phenytoin, antipsychotics, TCAs, steroids), pregnancy, examine for galactorrhea
- First, do a pregnancy test! Then check prolactin, LH, TSH, total testosterone
Heavy periods (menorrhagia) w/ regular intervals
- suggests ovulation, endocrine pathways are working.
- May have leiomyomata or polyps = increase the endometrial surface area
- May have coagulopathy – most often VWF disease or anticoagulant meds, also liver disease or thrombocytopenia
Light periods with regular intervals
– suspect Asherman syndrome, scarred, or obstructed cervical os.
PCOS
PCOS → irregular heavy periods
- Insulin resistance and androgen excess.
- Diagnosis: Must have 2 of 3: hyperandrogenism, chronic anovulation (causes menstrual cycle abnormalities – no luteal production of progesterone), and polycystic ovaries by ultrasound.
- Labs: measure serum total testosterone and sex hormone binding protein → calculate Free T.
- Treatment:
- Induce periods w/ periodic supplemental progesterone or with OCPs.
- Insulin issues: use metformin and thiazolidinediones (glitazones; work by activating PPAR-gamma)
- Infertility: clomiphene citrate, aromatase inhibitors, gonadotropins
Unpredictable timing and flow
Dysfunctional Uterine Bleeding (DUB) → abnormal hypothalamic-pituitary-ovarian axis.
- Most often after menarche/before menopause. Can signal anovulation.
- Management:
- Watch for a few years after menarche.
- < 35 y/o w/out risk factors for endometrial cancer → can treat without workup – use OCPs with combined estrogen and progestin or progestin alone.
- Work up if > 35 y/o. risk factors for endometrial cancer, no response to treatment, or postmenopausal.
- Diagnosis
- Initial work up: check prolactin, LH, TSH, total testosterone
- Transvaginal pelvic ultrasound and endometrial biopsy. Then hysteroscopy to visualize and direct any further biopsies – can do with D&C for diagnostic and therapeutic reasons.
Endometritis
- Common cause of vaginal spotting.
- Usually, polymicrobial infection ascended from vagina.
- Can involve gonorrhea, chlamydia, ureaplasma, peptostreptococcus, gardnerella vaginalis, and group B strep.
- Do endometrial biopsy – see inflamed cells, especially plasma cells.
