Menstrual disorders MENSTRUAL DISORDERS Outlines 1. Definition of menstrual disorders. 2. Classification of menstrual disorders. o Amenorrhea. o Dysmenorrhea (menstrual cramps). o Dysfunction uterine bleeding. The patterns of abnormal uterine bleeding may be in the form of menorrhagia, hypomenorrhea, oligomenorrhea, or Polymenorrhea. Objectives At the end of this lecture you will be able to: o Understand the definition of menstrual disorder. 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 menstrual cycle, causing pain, unusually heavy or light bleeding, delayed menarche, or missed periods. Deciphering Medical Terms for Menstrual Disorders Term Description Amenorrhea No periods Dysmenorrhea Painful periods Hypomenorrhea Regular menstruation occurring at normal intervals, but with minimal blood loss. Menorrhagia, or Regular menstruation occurring at normal hypermenorrhea intervals, but with heavy blood loss. Menometrorrhagia 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 menopause. bleeding Menstrual disorders Premenstrual Physical and psychological symptoms that syndrome (PMS) occur before the start of a period. Primary No periods ever starting (at puberty). 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 heavy menstrual bleeding, 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 ovaries or the hypothalamus or genetic abnormalities. Menstrual period should being within 2 years of breast development, 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 estrogen levels including stress, weight loss, exercise or illness. Additionally, problems affecting the pituitary gland =such as elevated levels of the hormone prolactin= or thyroid including hyperthyroidism or hypothyroidism= may cause secondary amenorrhea. This condition can also occur if there is an ovarian cyst. Classification according to the cause 1. Physiological amenorrhea: Normal or "Physiological" amenorrhea that is occurs before puberty, during childbearing as pregnancy & lactation, and after menopause. 2. Pathological amenorrhea which divided into: 1. False amenorrhea (cryptomenorrhea). Definition Menstruation occurs but blood escape is prevented due to obstruction (hidden menstruation). Etiology Congenital (absent vagina, transverse vaginal septum, imperforated hymen & non communicating horn of uterus). 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 Imperforate Hymen in a Patient with Bicornuate Uterus Signs and Symptoms 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 anemia). 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 (false pregnancy), anorexia nervosa depression, and prolonged vigorous exercise. o Prolactin drugs as (Estrogens). 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 childbirth. 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 (hypopituitarism) 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 cortisol. 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 androgens (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 dysgenesis, 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 cervix, 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 Endometritis 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 Androgen insensitivity syndrome is also called complete androgen