What is Abnormal Period
The menstrual history is critical to the diagnosis of
abnormal bleeding. The first day of the last menstrual periods should be
determined. Age of onset of menses (menarche) is also obtained, and the patient
should be asked to quantify whether she considers her flow to be light, moderate, or heavy;
some assessment of menstrual blood loss should be obtained if the patient
states that her flow is heavy.
The patient may be asked to estimate the total
number of pads or tampons used during a menstrual period or to estimate the
frequency with which they require changing. In addition, patients should be
asked about any bleeding between periods, and an effort should be made to
determine whether the bleeding, even if regular, is associated with ovulation.
The latter can be assessed by inquiring about the presence of regular moliminal
symptoms, including premenstrual breast tenderness, bloating, premenstrual
syndrome, and dysmenorrhea.
Unlike quantification of menstrual blood loss,
self-reports of moliminal symptoms have been shown to be reliable indicators of
ovulatory status. The complete absence of theses symptoms, as well as other
cycle-specific symptoms (such midcycle ovulatory pain or mucous changes),
should alert the physician to the possibility of anovulatory bleeding, which
may increase the patient’s risk for
adverse outcomes, such as infertility or endometrial neoplasia. Every patient
presenting with abnormal bleeding should be asked to keep a prospective
menstrual calendar, noting whether there is no bleeding.
Abnormal Bleeding Diagnosis
A history of prolonged heavy menses of more than 7 days´
duration with normal cycle interval suggest the diagnosis of menorrhagia. A history of consistent moliminal symptoms
should be present before the bleeding is assumed to be ovulatory. This
distinction is important is important because regular but anovulatory cycles
carry a greater risk of endometrial adenocarcinome. A history negative for
previous bleeding diathesis has been shown to obviate the need for hematologic
evaluation of clotting disorders.
Historical and clinical stigmata of possible
thyroid dysfunction, including heat and cold intolerance, diarrhea or
constipation, tachycardia, and thyromegaly, should also be determined. Although
the pelvic examination in women with menorrhagia is usually normal, bimanual examination may reveal the presence of
uterine fibroids or large cervical polyp. Documentation of ovulation is
important in any case of presumed menorrhagia in which ovulation cannot be
documented by the presence of consistent moliminal symptomatology. In these cases
ovulation can be documented by basal body temperature charting or by midluteal
progesterone determination.
Alternatively, particularly in cases of suspected
anovulatory bleeding, endometrial biopsy may be performed to rule out occult
endometrial hyperplasia or neoplasia. This is especially important in high risk
population, such as obese women, patients over the age of 35, or those with a
prolonged history of anovulatory bleeding. In addition, a complete blood count
is important in order to document possible concurrent anemia. Thyroid function
studies, including thyroxine and thyroid-stimulating hormone (TSH) are
indicated in many patient with clinical stigmata suggestive of possible thyroid
dysfunction. Similarly, coagulation studies and a bleeding time determination
may be indicated in patients with a history of bleeding following dental
extraction or epistaxis and bruising.
Abnormal Bleeding Treatment
A logical initial choice is scheduled antiprostaglandin
(prostaglandin synthetase inhibitor /PGSI/) therapy during the menstrual
period. This drugs increase the tromboxane to prostacyclin ratio in menstrual
blood and have been shown to decrease mean MBL by up to 50 percent.
Exogenous synthetic sex steroids have also been successfully
used for treatment of menorrhagia. We used medroxyprogesteronacetate (Provera)
for 10 to 14 days oral tablets, such as 5 to 30 mg. Similar success has been
documented with oral contraceptives. The contraceptive effects, improvement in
associated dysmenorrhea, and the wide margin of safety of low-dose oral
contraceptive make these highly desirable choices for nonsmoking women.
Adapted from: http://www.gyne.cz
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