sign in sign up
<<
Home , Amenorrhea, Bicornuate uterus, Cryptomenorrhea, Heavy menstrual bleeding, Hypomenorrhea, Menometrorrhagia

Menstrual disorders

MENSTRUAL DISORDERS

Outlines 1. Definition of menstrual disorders.

2. Classification of menstrual disorders.

o .

o (menstrual cramps).

o Dysfunction uterine bleeding. The patterns of abnormal uterine bleeding may be in the form of menorrhagia, , , or Polymenorrhea. Objectives

At the end of this lecture you will be able to:

o Understand the definition of .

o Identify and understand all about the Classifications of menstrual disorders.

Menstrual disorders

MENSTRUAL DISORDERS

Definition of menstrual disorders Menstrual disorder is a physical or emotional problem that interferes with the normal , causing pain, unusually heavy or light bleeding, delayed , or missed periods.

Deciphering Medical Terms for Menstrual Disorders

Term Description Amenorrhea No periods Dysmenorrhea Painful periods Hypomenorrhea Regular occurring at normal intervals, but with minimal blood loss. Menorrhagia, or Regular menstruation occurring at normal hypermenorrhea intervals, but with heavy blood loss.  Prolonged bleeding that occurs at irregular intervals Menometrorrhagia (meno = prolonged, metro = short, rrhagia = excessive flow/discharge). Metrorrhagia Bleeding that occurs at frequent, irregular intervals(spotting) Oligomenorrhea Abnormal prolongation of the intermenstrual period, every five weeks or more. Polymenorrhea Regular menstruation, which is normal in amount but it, occurs at short intervals, three weeks or less. Postmenopausal Bleeding that occurs after . bleeding Menstrual disorders

Premenstrual Physical and psychological symptoms that syndrome (PMS) occur before the start of a period. Primary No periods ever starting (at ). amenorrhea Secondary Periods that has stopped. amenorrhea Classification of menstrual disorders 1. Amenorrhea. 2. Dysmenorrhea (menstrual cramps). 3. Dysfunction uterine bleeding. The patterns of abnormal uterine bleeding may be in the form of menorrhagia, hypomenorrhea, oligomenorrhea, or Polymenorrhea. Amenorrhea Some women do not have , but they have the opposite problem no menstrual periods at all. This condition is called amenorrhea, or the absence of menstruation. There are two classification of amenorrhea according to the onset which divided into primary and secondary, and according to the causes which divided into physiological and pathological. (Coco, 1999)

Menstrual disorders

Classification according to the onset 1. Primary amenorrhea is diagnosed if the girl turns 16 yrs and hasn’t menstruated. It’s usually caused by some problem in the endocrine system which regulates the hormones. Sometimes these results from low body weight associated with eating disorders, excessive exercise or medications. This medical condition can be caused by a number of other things, such as a problem with the or the or genetic abnormalities. Menstrual period should being within 2 years of , usually between ages 10 to 16 yrs. Menstrual disorders

2. Secondary amenorrhea is diagnosed if the woman had regular periods, but they suddenly stop for three months or longer. It can be caused by problems that affect levels including , weight loss, exercise or illness. Additionally, problems affecting the =such as elevated levels of the hormone = or including or = may cause secondary amenorrhea. This condition can also occur if there is an . Classification according to the cause 1. Physiological amenorrhea: Normal or "Physiological" amenorrhea that is occurs before puberty, during childbearing as & , and after menopause. 2. Pathological amenorrhea which divided into: 1. False amenorrhea (). Definition Menstruation occurs but blood escape is prevented due to obstruction (hidden menstruation). Etiology Congenital (absent , transverse , imperforated & non communicating horn of ). Menstrual disorders

Ustrations of Hymen Types Acquired (cervical cautery, amputation and conization & suturing anterior wall to posterior wall during C.S).

Pathology Menstrual blood retained above the level of obstruction leading to haematocolpos (blood retained in the vagina), hematomata (bleeding of or near the uterus it can be caused by a proximal transverse vaginal septum), haematosalpinx ( bleeding into the fallopian tubes), & haemoperitoneum (the presence of blood in the peritoneal cavity. the blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. (http//content.nejm.org/content/vol351/issue7/images/large/15f1.jpeg) Menstrual disorders

Hematometrocolpos Due to in a Patient with

Amenorrhea, Lower abdominal cyclic pain (repeated every month) Pelviabdominal swelling, distended vagina with blood leads to compression on urethra, stretching retention of urine & difficulty in micturation.

Signs of cryptomenorrhea 1. General examination: All secondary sexual characteristics are developed. 2. Abdominal examination: dull cystic pelviabdominal mass (haematocolpos). 3. Vaginal examination: Bulging bluish di s t end e d hymen indicates imperforated hymen. 4. Per rectum examination (PIR): cystic swelling felt in front rectum. 5. Investigation by ultrasonography cystic pelviabdominal mass.

Menstrual disorders

Treatment:

1. Active treatment depends on the site of obstruction.

2. Circulate incision for imperforated hymen.

3. Excision for transverse vaginal septum. 2. True amenorrhea Etiology: 1. General causes as: o Endocrinal causes as (hypo and hyperthyroidism, uncontrolled D.M and adrenal gland disorder). o Non-endocrinal causes as (Debilitating disease as T.B. malignancy & liver failure, obesity, under weight and severe ). 2. Specific causes as:

1. CNS and Hypothalamic amenorrhea:

Etiology: o Organic lesions, traumatic, inflammatory as meningitis and encephalitis or neoplasm. o Psychological disturbance as pseudocyesis (), depression, and prolonged vigorous exercise. o Prolactin drugs as (). Menstrual disorders

2. Pituitary amenorrhea 1. Trauma as surgical trauma. 2. Inflammation (T.B or syphilis). 3. Vascular (radiation). 4. Tumors as prolactin secreting pituitary tumors (proloctinoma) it is the commonest cause of pituitary amenorrhea. 5. Sheehan’s syndromes: - is a condition affecting women who experience life-threatening blood loss during or after . Severe blood loss deprives the body of oxygen and can seriously damage vital tissues and organs. In Sheehan's syndrome the damage occurs to the pituitary gland. The result is the permanent underproduction of essential pituitary hormones () also called postpartum hypopituitarism. 3. Adrenal causes of amenorrhea: 1. Cushing syndrome. o Cushing’s syndrome is a hormonal disorder caused by prolonged exposure of the body’s tissues to high levels of the hormone . 2. Congenital adrenal hyperplasia. o It is a family genetic condition affecting the adrenal glands. It can interfere with normal growth and development in children including normal development of the genitals. It affects both males and females. Menstrual disorders

o Congenital adrenal hyperplasia may also result in the adrenals making abnormal levels of two other classes of hormones mineralocorticoids (aldosterone) and (testosterone). Although congenital adrenal hyperplasia can be life- threatening most people with it can lead normal lives with proper treatment. 4. Ovarian amenorrhea 1. Congenital gonadal agenesis also called ovarian agenesis, , gonadal aplasia, or Turner's syndrome it is a rare inherited chromosomal disorder of females characterized by short stature and absence of sexual development at puberty. Other physical features may include a webbed neck, heart defects, kidney abnormalities, and various other malformations such as coarctation of the aorta, and abnormalities of the eyes and bones. 2. Traumatic (surgical removal). 3. Vascular (post irradiation) and neoplastic. 5. Uterine amenorrhea 1. Congenital: as Müllerian agenesis & hypoplasia. . The müllerian ducts are the primordial anlage of the female reproductive tract. They differentiate to form the fallopian tubes, uterus, the uterine , and the superior aspect of the vagina. A wide variety of malformations can occur when this system is disrupted. They range from uterine and vaginal agenesis to duplication of the uterus and vagina to minor uterine cavity abnormalities. Müllerian malformations are Menstrual disorders

frequently associated with abnormalities of the renal and axial skeletal systems and they are often the first encountered when patients are initially examined for associated conditions. 2. Traumatic: as surgical removal or traumatic Asherman also called "uterine synechiae" or intrauterine adhesions (IUA) it characterized by the presence of adhesions and/or fibrosis within the uterine cavity due to scars. 3. Inflammatory: as T.B or inflammatory Asherman. 4. Vascular: as post irradiation. 6. Chromosomal causes 1. The super female or triple x syndrome: -The super female or triple x syndrome is a form of chromosomal variation characterized by the presence of an extra X chromosome in each cell of a human female. 2. Testicular Feminization or insensitivity syndrome is also called complete androgen insensitivity syndrome this is a genetic disorder that makes XY fetuses insensitive (unresponsive) to androgens (male hormones). Instead they are born looking externally like normal girls. Internally, there is a short blind-pouch vagina and no uterus, fallopian tubes or ovaries. There are testes in the abdomen or the inguinal canal. The complete androgen insensitivity syndrome is usually detected at puberty when a girl should menstruate but does not Menstrual disorders begin to menstruate, many of the girls with the syndrome have no pubic or axillary (armpit) hair. They are sterile and cannot bear children. They are at high risk for and so should take estrogen replacement therapy. Diagnosis of Amenorrhea [A] History: 1. Personal history: Age of the patient to exclude menopause, and Occupation. 2. Marital state to exclude pregnancy. 3. Present history of wasting, obesity, insomnia, glactorrhea, psychological disturbances and hot flushes. 4. Menstrual history: type of amenorrhea primary or secondary and its duration 5. Obstetric history particularly for traumatic Asherman (intrauterine adhesions). 6. Past history of D.M. &T.B, curettage, and irradiation. 7. Family history of D.M. &T.B. testicular feminization and PCO. [B] General Examination: 1. Physical & sexual development (absence of secondary sexual characters). 2. Height: Short as (Frolich and Laurence – Moon – Biedle syndrome). 3. Weight: Very thin (anorexia nervosa & hypothyroidism) - Obese (P.C.O Frolich, Cushing, Moon biedl syndromes). 4. Hirsuitism. Menstrual disorders

5. Examination of the thyroid, chest, and breasts and galactorrhea is excluded by squeezing all quad rants of both breasts. 6. Examination of urine for sugar, protein and casts (for D.M and chronic renal disease). [C] Abdominal examination:  For a pelvi-abdominal mass as pregnancy or haematocolpos. [D] Local examination:  For , , vagina, cervix, ovaries and the presence of pelvic masses. [E] Special investigations:  Work up of an amenorrheic patient after excluding pregnancy by B unit (HCG).  Estimation of serum TSH and prolactin as is responsible for 20% of cases of secondary amenorrhea. challenge test Progestogen as norethinsterone 5 mg is given twice daily for five days as causes uterine bleeding if the has been primed with estrogen. It means that the is producing estrogen alone but not progesterone. No bleeding occurs means either the ovary is not producing estrogen or the uterus is not responding as (intrauterine adhesions). Estrogen Progestogen challenge test A combined oral constructive pill is given for three weeks. If Menstrual disorders bleeding occurs the fault is in the ovary not producing estrogen. This denotes any cause above uterine level, if no bleeding. This denotes uterine defect or uterine amenorrhea Serum FSH and LH A high serum level of FSH (above 40mIu/ ml) Indicates ovarian failure and the ovary are not producing estrogen. Investigations for ovarian amenorrhea by:  Ultrasonography diagnoses PCO, streak & used. Investigations for the adrenal glands:  Estimation of serum cortisol and ACTH (adrenocorticotropin hormone) to diagnose Cushing syndrome.  CT and MRI for diagnosis of pituitary amenorrhea. & exclude adrenal tumor. Investigation for pituitary amenorrhea:  Glucose tolerance tests if we suspect D.M.  Estimation of Hb.  Chromosomal study must be done in every case of primary amenorrhea 40% of these cases show chromosomal abnormalities Treatment of Amenorrhea: 1. General treatment: [Proper diet & Treatment of anemia if present; Psychotherapy if necessary]. 2. Treatment of the cause: [As control of D.M, treatment T.B and Hyperprolactinaemia is treated by a dopamine agonist as Menstrual disorders

bromocriptin (Parlodel) or lisuride (Dopergin). 3. Hormonal treatment it is indicated in absence of an organic cause (dysfunctional amenorrhea). 4. Cyclic treatment with estrogen followed by Progesterone for 3 successive months. 5. Induction of . Clomiphene (clomid) .Thyroxin or thyroid extract for hypothyroidism. 6. Corticosteroids as prednisolone (congenital adrenal hyperplasia). Menstrual Cramps (Dysmenorrhea) Most women have experienced menstrual cramps before or during their periods at some point in their lives. For some, it is part of the regular monthly routine, but if cramps are especially painful and persistent, this is known as dysmenorrhea. This disorder is classified into primary and secondary a. Primary dysmenorrhea or (spasmodic and membranous dysmenorrhea). I. Spasmodic dysmenorrhea is a common complaint in young girls (teenagers) pain occurs in absence of any organic pelvic lesion.  Age: (starts 1 or 2 years after menarche).  Parity: pain improves with abortion or labor.  Type of pain: colicky intermittent pain starts on the first day of menstruation and ceases with the onset of menstruation blood flow.  Region: It felt in the supra public area and in the front and inner sides of thigh. Menstrual disorders

Etiology: More than one theory explains spasmodic dysmenorrhea:  Abnormal anatomy: As Cervical obstruction &  Abnormal physiology: o Low pain threshold, uterine ischemia, Hormonal imbalance, and Prostaglandin effect causes contraction of the gut muscle, nausea, Vomiting and diarrhea.  General causes: As psychological disturbance and smoking. II. Membranous dysmenorrhea: It is a rare type of spasmodic dysmenorrhea in which severe pain is relieved only by passage of an endometrial cast during 3rd or 4th day of menstruation. Signs and symptoms: 1. Pain concentrated in the lower abdomen, in the umbilical region or the suprapubic region of the abdomen. It is also commonly felt in the right or left abdomen. 2. It may radiate to the thighs and lower back. nausea and vomiting, diarrhea or constipation, headache, dizziness, disorientation, hypersensitivity to sound, light, smell and touch, fainting, and fatigue. Symptoms of dysmenorrhea often begin immediately following ovulation and can last until the end of menstruation. This is because dysmenorrhea is often associated with changes in hormonal levels in the body that occur with ovulation. The use of certain types of Menstrual disorders

pills can prevent the symptoms of dysmenorrhea, because the birth control pills stop ovulation from occurring. Treatments 1. Nutritional Several nutritional supplements have been indicated as effective in treating dysmenorrhea, including magnesium, zinc, and thiamine (vitamin B1), Intake of thiamine was demonstrated to provide "curative" relief in 87% of females experiencing dysmenorrhea. Sources of vitamin B1 include (cereals especially bread, and brown rice other foods that contain this vitamin include dairy products, yeast extract, nuts, seeds, and red meat), omega-3 fatty acids the richest dietary source of omega-3 fatty acids is found in flax oil and sardine, vitamin E oral intake of vitamin E relieves the pain of primary dysmenorrhea and reduces blood loss. NSAIDs Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving the pain of primary dysmenorrhea, can have side effects of nausea, dyspepsia, peptic ulcer, and diarrhea. Hormonal contraceptives Non-drug therapies Several non-drug therapies for dysmenorrhea have been studied, including behavioral, acupuncture, acupressure, chiropractic care, and the use of a TENS unit. 2. Hormonal treatments One study suggested that vasopressin antagonists might be useful in treating a variety of disorders, including dysmenorrhea. (Lemmens, et al 2008) Menstrual disorders

b. Secondary dysmenorrhea Secondary dysmenorrhea is dysmenorrhea which is associated with an existing condition. The most common cause of secondary dysmenorrhea is . Other causes include . , ovarian cysts, and pelvic congestions, the presence of a copper IUD can also cause dysmenorrhea. Clinical picture:  Age (>30 years).  Parity (more in porous).  Type of pain (dull ache fell in lower abdomen and low back starts 3- 5 days before the period and end with the onset of flow.  Associated symptoms: menorrhagia, Polymenorrhea and leucorrhea. Treatment of secondary dysmenorrhea: 1- Treatment of the cause. 2- 2- . 3- Measures to relieve pelvic congestion as warm vaginal douches. Nursing Management  Instruction in menstrual hygiene-so that her period does not seem distasteful and restricting, encourage frequent bathing  Encourage to get more good posture and exercise particularly aerobics (cycling, jogging, walking, and waist bending before the onset of the period) Menstrual disorders

 Avoidance over fatigue and overexertion during the period  Apply heat (e.g. warm baths, putting a hot water bottle, or heating pads on the abdomen)  Focuses on education and psychosocial needs of the patient.  Encourages drinking plenty of fluids, but avoiding alcohol.  Divert attention  Encourage rest and sleep III. Abnormal Uterine Bleeding Dysfunctional uterine bleeding can be caused by hormonal imbalances 75% of women with excessive menstrual bleeding have a hormone-related disorder that is responsible for their abnormal uterine bleeding condition. Hormonal imbalances occurs when the body produces too much or not enough of certain hormones. These imbalances may also be associated with weight loss or gain of more than 15 pounds, a heavy exercise regimen, significant stress, illness, and use of some medications such as antianxiolytics like valium, and certain antipsychotic medications The patterns of abnormal uterine bleeding may be in the form of menorrhagia, hypomenorrhea, oligomenorrhea, or Polymenorrhea. a. Menorrhagia (hypermenorrhea): Menorrhagia means regular menstruation occurring at normal intervals, but it is excessive in amount or prolonged in duration or both. (National Women's Health Resource Center, 2006). Causes Menstrual disorders

There are several possible causes of menorrhagia, including the following: Hormonal (particularly estrogen and progesterone) imbalance (especially seen in adolescents who are experiencing their menstrual period for the first time and in women approaching menopause). Pelvic inflammatory disease (PID). Uterine fibroids. Abnormal pregnancy (i.e., , ectopic). Infection, tumors, or polyps in the pelvic cavity. Certain birth control devices (i.e., intrauterine devices or IUDs). Bleeding or disorders. Liver, kidney, or .

Symptoms of menorrhagia In general, bleeding is considered excessive when a woman changes a soaks sanitary pad every hour. In addition, bleeding is consideredprolonged when a woman experiences a menstrual period that lasts longer than 7 days in duration. The following are the most common symptoms of menorrhagia. However, each individual may experience symptoms differently. Symptoms may include: Spotting or bleeding between menstrual periods Spotting or bleeding during pregnancy. Diagnosis Diagnostic procedures for menorrhagia include the following: Menstrual disorders

Blood tests  (also called sonography) Biopsy (endometrial):- : - a visual examination of the canal of the cervix and the interior of the uterus using a viewing instrument hysteroscope inserted through the vagina.  (d & c) Complications Anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration. Treatment for menorrhagia includes:  supplementation (if the condition is coupled with anemia, a blood disorder caused by a deficiency of red blood cells or )

Prostaglandin inhibitors such as nonsteroidal anti- inflammatory medications (nsaids) such as aspirin or ibuprofen (to help reduce cramping and the amount of blood expelled). Oral contraceptives (ovulation inhibitors).

Progesterone (hormone treatment).

: is a treatment that destroys or removes most of the lining of the uterus. Endometrial resection:-a procedure to remove the lining of the uterus (endometrium). Menstrual disorders

:surgical removal of the uterus. b. Hypomenorrhea: It means regular menstruation occurring at normal intervals, but with minimal blood loss (National Women's Health Resource Center, 2006). Causes 1. Asherman's syndrome (intrauterine adhesions) in which (hypomenorrhea or amenorrhea) may be the only apparent sign. The degree of menstrual deficiency is closely correlated to the extent of the adhesions. 2. Constitutional: In some women it may be normal to have less bleeding during menstrual periods. Less blood flow may be genetic and if enquiries are made it may be found that woman’s mother and/or sister also have decreased blood flow during their periods. 3. Uterine: Scanty loss sometimes means that the bleeding surface is smaller than normal, and is occasionally seen when the endometrial cavity has been reduced in size during myomectomy or other plastic operation on the uterus. 4. Hormonal: Scanty menses or periods can occur normally at the extremes of the reproductive life that is just after puberty and just before menopause. Scanty menses can also occur after long-term use of oral contraceptive as a result of progressive endometrial atrophy. 5. Nervous and emotional: Psychogenic factors like stress due to exams, or excessive excitement about an upcoming event Menstrual disorders

may cause hypomenorrhea. Such factors suppress the activity of those centers in the brain that stimulate ovaries during the ovarian cycle to secrete hormone like estrogen and progesterone and may result in low production of these hormones. 6. Other causes: Excessive exercise and crash can cause scanty periods. One of the causes of hypomenorrhea is Asherman’s syndrome in which hypomenorrhea may be the only apparent sign. The degree of menstrual deficiency is closely correlated to the extent of (Toaff, et al, 2008). Diagnosis Blood Tests: Most of the common cause of decreased flow of blood during the menses can be detected by blood tests. Tests for the level of hormones like FSH, LH, estrogen, prolactin, are important. In polycystic , there will be high levels of insulin and androgens. Ultra sonogram: An ultra sonogram can diagnose the thickness of the endometrium, size of the ovaries growth of follicles, ovulation and other abnormalities. Other tests: Tests like D & C and MRI scans are some times needed to find out the cause of scanty blood flow during the periods. Treatment

 Unless a significant causal abnormality is found no treatment Menstrual disorders

other than reassurance is necessary. c. Oligomenorrhea: It means abnormal prolongation of the intermenstrual period every five weeks or more. Prolongation usually affects the of the ovarian cycle (National Women's Health Resource Center, 2006). Symptoms of Oligomenorrhea Periods that come more than 35 days apart Fewer than 4 to 9 periods a year Difficulty conceiving Easily broken or fractured bones Causes of Oligomenorrhea Period irregularities are usually caused by environmental factors, which can easily be changed to help reintroduce a normal period. These factors include: Emotional stress Over exercise Physical illness Frequent travel

Poor nutrition Sometimes oligomenorrhea result from physiological problems which must be addressed in order to restore normal menstruation. These include: Confused Messages: Sometimes, is the result of a lack of synchronization between your hypothalamus, pituitary gland, and ovaries. In order to stimulate ovulation these three parts of your body need to send messages to one another in a specific order. Sometimes Menstrual disorders

these messages get confused resulting in a missed period. Hormonal Imbalances: Oligomenorrhea is commonly the result of hormonal imbalances. When the body produces too many male hormones called androgens, and too few female hormones, called estrogens ovulation can become irregular. Women who use anabolic steroids, certain prescription medications, or who have eating disorders often have hormonal imbalances. Polycystic ovarian syndrome: is one of the more common causes of oligomenorrhea. In PCOS, the body creates too many androgens, which causes tiny cysts to form inside the ovaries. This causes infrequent ovulation and menstruation. Treatments for Oligomenorrhea Treatments for oligomenorrhea depend upon the cause of infrequent periods. 1. Reduce Environmental Stressors If environmental factors are contributing to the infrequency, addressing these issues is the best bet. Try to ensure you get good nutrition, maintain a healthy weight, and reduce your stress levels. 2. Medications Women with PCOS and other hormonal imbalances can be given medication in order to restore their hormone levels. Birth control pills or other hormonal forms of birth control can help to balance out hormones and restore menstruation. Menstrual disorders

Women with high levels of androgens can use anti-androgen medications in order to encourage ovulation. Menstrual disorders

d. Polymenorrhea: It means regular menstruation, which is normal in amount but it occurs at short intervals, three weeks or less Symptoms Polymenorrhea is a condition in which a period occurs every two to three weeks instead of every four weeks. This condition can lead to health problems due to blood loss. Causes Polymenorrhea has similar causes for girls in puberty as well as adult women. If the anterior pituitary gland is hyperactive it can cause rapid ovulation. Additionally, malnutrition and pelvic disorders can lead to Polymenorrhea. Treatment Anemia medication, improved diet, medication and treatment of any pelvic disorder can all help to treat Polymenorrhea. In some cases estrogen or progesterone

therapy may be necessary. (http://www.ehow.com/facts_6465702polymenorrhea-during- puberty.html)