7.1 Menstrual Disorders, Endometriosis & Fibroids

Abnormal Uterine Bleeding (AUB) and PALM-COEIN

Abnormal uterine bleeding in non-pregnant, reproductive-aged women is universally classified using the FIGO PALM-COEIN system, which divides etiologies into structural (PALM) and non-structural (COEIN) causes. A thorough clinical history, physical examination, and selective diagnostic testing are required to pinpoint the underlying etiology.

Management of Acute HMB: Initial stabilization is paramount. Medical management for acute, severe bleeding includes high-dose intravenous estrogen (which rapidly induces endometrial growth to cover denuded areas), multi-dose oral contraceptives, or tranexamic acid (an antifibrinolytic agent). Surgical options for intractable bleeding include uterine artery embolization (UAE) or dilatation and curettage (D&C), which provides rapid hemostasis.

Long-term Management: The levonorgestrel-releasing intrauterine device (LNG-IUD) is highly effective and often considered first-line for chronic management. Other options include combined oral contraceptives, oral progestins (given for 21 days or continuously), or NSAIDs, which decrease prostaglandin synthesis and reduce blood loss by 20-30%.

Endometriosis

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity, most commonly on the ovaries (endometriomas or 'chocolate cysts'), posterior cul-de-sac, uterosacral ligaments, and pelvic peritoneum. It is an estrogen-dependent, chronic inflammatory condition that predominantly affects women of reproductive age.

Clinical Presentation:

• The 3 D's: Dysmenorrhea (often cyclical, worsening over time and unresponsive to NSAIDs), Dyspareunia (typically deep, due to cul-de-sac involvement), and Dyschezia (pain with defecation, suggesting rectovaginal septum disease).
• Chronic pelvic pain, which may become non-cyclical over time due to central sensitization.
• Infertility, caused by anatomical distortion from dense pelvic adhesions or a toxic inflammatory microenvironment affecting sperm and egg function.

Diagnosis:

• Clinical: Suspected based on history and physical exam findings such as nodularity of the uterosacral ligaments, a fixed retroverted uterus, or adnexal masses.
• Imaging: Transvaginal ultrasound (TVUS) can identify endometriomas (appearing as cysts with homogenous, low-level internal echoes) but has poor sensitivity for superficial peritoneal implants.
• Definitive: Diagnostic laparoscopy with direct visualization and histological confirmation of biopsy remains the gold standard.

Management:

• First-line medical: NSAIDs for pain, combined with continuous hormonal contraceptives (oral, patch, or ring) or progestin-only pills to suppress ovulation, reduce estrogen levels, and induce atrophy of endometriotic implants.
• Second-line medical: GnRH agonists (e.g., leuprolide) which create a hypoestrogenic 'pseudomenopause'. These are often given with add-back estrogen/progestin therapy to prevent osteoporosis and severe vasomotor symptoms. GnRH antagonists (e.g., elagolix) are newer oral alternatives.
• Surgical: Conservative surgery (excision or ablation of implants and adhesiolysis) is indicated for pain refractory to medical therapy or to improve fertility. Definitive surgery (hysterectomy with or without bilateral salpingo-oophorectomy) is reserved for severe, refractory cases when fertility is complete.

Uterine Fibroids (Leiomyomas)

Fibroids are benign, monoclonal tumors derived from the smooth muscle cells of the myometrium. They are the most common solid pelvic tumor in women. Their growth is stimulated by both estrogen and progesterone.

Classification:

1. Submucosal: Protrude into the uterine cavity. They are the most symptomatic type, frequently causing heavy menstrual bleeding and recurrent pregnancy loss by disrupting the endometrial cavity.
2. Intramural: Located completely within the myometrial wall. This is the most common type.
3. Subserosal: Project outward from the serosal surface of the uterus. They can become pedunculated and undergo acute torsion, causing severe acute pelvic pain.

Clinical Presentation: Most fibroids are asymptomatic and discovered incidentally. When symptomatic, patients commonly present with heavy or prolonged menstrual bleeding, pelvic pressure, urinary frequency (due to anterior fibroids pressing on the bladder), and constipation. On bimanual examination, the uterus is typically enlarged, irregularly shaped, and non-tender.

Management:

• Expectant: Observation is appropriate for asymptomatic patients.
• Medical: Directed primarily at symptom control rather than tumor eradication. Options include NSAIDs, tranexamic acid, and hormonal contraceptives. GnRH agonists can shrink fibroids by up to 50% temporarily, which is particularly useful pre-operatively to correct anemia and reduce intraoperative blood loss.
• Surgical:
  • Myomectomy: Surgical removal of the fibroids while leaving the uterus intact. This is the procedure of choice for women who desire future fertility.
  • Hysterectomy: The definitive treatment for women who have completed childbearing.
  • Uterine Artery Embolization (UAE): A minimally invasive interventional radiology procedure that cuts off the blood supply to the fibroids, leading to necrosis and shrinkage. It is generally avoided in patients desiring future pregnancy due to an increased risk of placental abnormalities (e.g., placenta accreta) and adverse obstetric outcomes.

Polycystic Ovary Syndrome (PCOS)

PCOS is a complex and common endocrine disorder characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. It is fundamentally linked to insulin resistance and metabolic syndrome, significantly increasing the long-term risk of type 2 diabetes, cardiovascular disease, and endometrial cancer (due to unopposed estrogen from chronic anovulation).

Diagnosis (Rotterdam Criteria - Requires 2 of 3 for diagnosis):

1. Oligo-ovulation or anovulation (manifesting as irregular, infrequent menstrual periods).
2. Clinical hyperandrogenism (hirsutism, severe acne, male-pattern alopecia) OR biochemical hyperandrogenism (elevated serum total or free testosterone).
3. Polycystic ovaries on transvaginal ultrasound (defined as ≥20 small follicles per ovary or increased ovarian volume ≥10 mL).

Management:

• Lifestyle modifications: Weight loss and dietary changes are first-line; a reduction of just 5-10% of body weight can significantly improve insulin sensitivity and restore ovulatory cycles in many women.
• Menstrual regulation: Combined oral contraceptives (COCs) are the mainstay of treatment for women not seeking pregnancy. They protect the endometrium from hyperplasia, regulate bleeding, and increase Sex Hormone-Binding Globulin (SHBG) production in the liver, which effectively lowers circulating free testosterone levels.
• Hirsutism: Managed with cosmetic hair removal methods and systemic anti-androgens like spironolactone (requires concurrent contraception due to the risk of feminization of a male fetus).
• Infertility: Letrozole (an aromatase inhibitor) is now considered the first-line pharmacological treatment for ovulation induction in women with PCOS, as it yields higher live birth rates and a lower risk of multiple gestations compared to clomiphene citrate.
• Metabolic: Metformin is indicated for patients with documented impaired glucose tolerance or type 2 diabetes, though it is less effective than letrozole for ovulation induction when used alone.

Pelvic Organ Prolapse & Urinary Incontinence

Pelvic organ prolapse results from weakness of the pelvic floor supporting the uterus, bladder, or rectum after vaginal childbirth and aging.

• Cystocele (bladder), rectocele (rectum), and uterine prolapse are graded by the Pelvic Organ Prolapse Quantification (POP-Q) system.
• Management: conservative with pelvic-floor (Kegel) exercises and a pessary; surgical reconstruction (sacrocolpopexy) for symptomatic prolapse.

Urinary incontinence:

Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD)

PMS involves recurrent physical (breast tenderness, bloating) and mood symptoms in the luteal phase that resolve with menses. PMDD is the severe form, with marked affective symptoms (irritability, depressed mood, anxiety) that impair function.

• Diagnosis: a prospective symptom diary over ≥2 cycles confirming luteal-phase timing and symptom-free follicular phase.
• Treatment: first-line is lifestyle modification and combined oral contraceptives (which suppress ovulation); second-line is a selective serotonin reuptake inhibitor (SSRI) taken continuously or in the luteal phase.