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Menstural disorder according to bereks and novaa gyne book

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I now have comprehensive content from Berek & Novak's Gynecology. Let me compile the complete answer.

Menstrual Disorders

Source: Berek & Novak's Gynecology (ISBN 9781496380357)

1. Normal Menstrual Cycle

After adolescence, menstrual cycles conform to a cycle length of 21–35 days, with duration of flow fewer than 7 days. Key parameters:
ParameterNormal Range
Cycle length21–35 days
Duration of flow≤7 days
Mean duration of menses4.7 days
Average blood loss35 mL/cycle
Heavy menstrual bleeding (HMB)>80 mL/cycle
As a woman approaches menopause, cycles become more irregular due to fewer ovulatory cycles.

2. Terminology & Classification (FIGO/ACOG)

Imprecise older terms like menorrhagia, menometrorrhagia, and dysfunctional uterine bleeding (DUB) are no longer recommended. The current standard is the PALM-COEIN system (FIGO/ACOG), which describes bleeding by:
  • Regularity
  • Frequency
  • Duration
  • Heaviness of flow

PALM-COEIN Acronym

PALM = Structural causes:
  • P — Polyp (AUB-P)
  • A — Adenomyosis (AUB-A)
  • L — Leiomyoma (AUB-L)
  • M — Malignancy & Hyperplasia (AUB-M)
COEIN = Non-structural causes:
  • C — Coagulopathy (AUB-C)
  • O — Ovulatory dysfunction (AUB-O)
  • E — Endometrial (AUB-E)
  • I — Iatrogenic (AUB-I)
  • N — Not yet classified (AUB-N)

3. Causes of Abnormal Uterine Bleeding (AUB) by Category

AUB-A: Adenomyosis

Endometrial glands and stroma embedded within the myometrium, causing heavy and painful periods.

AUB-L: Leiomyoma (Fibroids)

Uterine fibroids are among the most common causes of HMB in the reproductive age group; most common benign pelvic tumor in women.

AUB-M: Malignancy & Hyperplasia

Endometrial cancer and hyperplasia must always be excluded, especially in perimenopausal and postmenopausal women.

AUB-C: Coagulopathy

Bleeding disorders (e.g., von Willebrand disease) are an underrecognized cause of HMB. Should be considered especially in adolescents with heavy bleeding from menarche.

AUB-O: Ovulatory Dysfunction

Most common cause of irregular bleeding in the reproductive age group. Causes include:
  • PCOS (5–8% of adult women; associated with insulin resistance, androgen excess, cardiovascular risk)
  • Thyroid disease (hypothyroidism → menorrhagia; hyperthyroidism → oligomenorrhea)
  • Hyperprolactinemia
  • Stress, eating disorders (anorexia/bulimia), excessive exercise
  • Primary ovarian insufficiency (POI)
  • Diabetes mellitus
  • Alcohol/drug use

AUB-E: Endometrial

In ovulatory cycles, imbalance of local vasoconstrictors (endothelin-1, PGF2α) vs. vasodilators (prostacyclin I2, PGE2) may cause HMB. Endometritis (including chlamydial infection) can also cause excessive flow.

AUB-I: Iatrogenic

Breakthrough bleeding is very common with hormonal contraceptives:
  • Occurs in 30–40% of OCP users in the first 1–3 months
  • Can occur with inconsistent use, patches, vaginal ring, IUDs, progestin implants
  • Usually managed expectantly

AUB-N: Not Yet Classified

Rare or poorly understood entities (e.g., arteriovenous malformations).

4. Causes by Age Group

Age GroupMost Common Causes
InfancyMaternal estrogen withdrawal
PrepubertalVulvovaginitis, vaginal foreign body, precocious puberty
AdolescentAnovulation, coagulopathy, pregnancy, exogenous hormones
ReproductiveExogenous hormones, pregnancy, anovulation, fibroids, polyps
PerimenopausalAnovulation, fibroids, cervical/endometrial polyps, thyroid dysfunction
PostmenopausalAtrophy, endometrial polyps, endometrial cancer, HRT
Pregnancy must always be excluded in women of reproductive age presenting with AUB.

5. Diagnosis of AUB

History: Cycle regularity, flow volume, duration, intermenstrual or postcoital bleeding, medication use.
Laboratory Studies:
  • Pregnancy test (all reproductive-age women)
  • CBC, TSH, prolactin
  • Coagulation studies if coagulopathy suspected
Imaging:
  • Transvaginal ultrasound (first-line)
  • Sonohysterography (saline infusion) for intracavitary lesions
Endometrial Sampling: Indicated in:
  • Women >45 years
  • Younger women with risk factors (obesity, prolonged anovulation, tamoxifen use, diabetes)
  • Persistent or unexplained AUB

6. Management of AUB

Nonsurgical (Medical) Management

  • NSAIDs — reduce flow by ~30–50% via COX inhibition
  • Tranexamic acid — antifibrinolytic; reduces flow
  • Combined OCP — regulates cycle, reduces flow
  • Progestins — cyclic or continuous
  • LNG-IUS (Mirena) — highly effective for HMB; reduces flow by ~80–90%
  • GnRH agonists — for preoperative reduction; not for long-term use without add-back

Surgical Management (if medical therapy fails)

  • Endometrial ablation
  • Hysterectomy (definitive)
  • Myomectomy (for leiomyoma-associated bleeding)

7. Dysmenorrhea

Definition: Painful menstruation.

Primary Dysmenorrhea

  • Menstrual pain without pelvic pathology
  • Affects up to 60% of menstruating women
  • Appears within 1–2 years of menarche when ovulatory cycles are established
Pathophysiology: Excessive prostaglandins (especially PGF2α and PGE2) secreted from secretory endometrium → increased uterine contractions, raised basal tone, decreased uterine blood flow, peripheral nerve hypersensitivity.
Symptoms: Suprapubic cramping, lumbosacral back pain, radiation to anterior thigh, nausea, vomiting, diarrhea. Begins a few hours before or at onset of menses; lasts 48–72 hours.
Treatment:
  • NSAIDs (first-line) — COX inhibitors reduce prostaglandin synthesis
  • Combined oral contraceptives
  • LNG-IUS
  • Heat, exercise, dietary changes

Secondary Dysmenorrhea

  • Painful menses with underlying pathology (endometriosis, adenomyosis, fibroids, PID, congenital anomalies)
  • Usually develops years after menarche; can occur with anovulatory cycles

8. Amenorrhea

Definition:
  • Primary amenorrhea: No menarche by age 15 with secondary sexual characteristics, or by age 13 without them
  • Secondary amenorrhea: Absence of menses for ≥3 months in a previously menstruating woman

Classification Framework

A. Without Secondary Sexual Characteristics (↑FSH/LH = hypergonadotropic hypogonadism)
  • Turner syndrome (45,X): Most common cause. Streak ovaries, short stature, webbed neck, shield chest, cubitus valgus, low hairline. Y cell line must be excluded (gonadoblastoma risk → gonadectomy required).
  • Gonadal dysgenesis (46,XX, 46,XY)
  • Enzyme deficiencies (e.g., 17α-hydroxylase)
  • Hypogonadotropic hypogonadism (↓FSH/LH): Kallmann syndrome, constitutional delay, hypothalamic dysfunction
B. With Secondary Sexual Characteristics + Anatomic Abnormalities
  • Müllerian anomalies (imperforate hymen, vaginal septum, absent uterus — Mayer-Rokitansky-Küster-Hauser syndrome)
  • Androgen insensitivity syndrome (46,XY; female phenotype; absent uterus)
C. With Secondary Sexual Characteristics + Normal Pelvic Anatomy
  • Hypothalamic dysfunction (stress, weight loss, exercise)
  • Hyperprolactinemia (pituitary adenoma)
  • PCOS
  • Thyroid or adrenal disease
  • Asherman syndrome (intrauterine adhesions)
  • Primary ovarian insufficiency (POI)
  • Pregnancy (always first to exclude)

9. Premenstrual Syndrome (PMS) / Premenstrual Dysphoric Disorder (PMDD)

Integrative and pharmacologic approaches are used. Evidence-based supplement options (from the integrative medicine chapter):
SupplementEvidence
Calcium 1,200–1,600 mg/dayStrong — significant reduction of luteal phase symptoms
Vitamin B6 ≤100 mg/dayModerate — benefit for mastalgia, depression (>200 mg/day carries neuropathy risk)
Magnesium 200–400 mg/dayModest; B6+Magnesium combination shows benefit
Omega-3 fatty acids (EPA+DHA)Anti-inflammatory; reduces symptom severity
Source: Berek & Novak's Gynecology — Chapters 10 (Reproductive Age AUB), 12 (Dysmenorrhea), 34 (Amenorrhea), and related sections on PALM-COEIN classification.
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