Division of Reproductive Health MENSTRUAL DISORDERS MELY K.
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Transcript of Division of Reproductive Health MENSTRUAL DISORDERS MELY K.
Division of Reproductive Health
Specific Objectives• By the end of this session the Learner will be
able to:– Define Normal menstruation– Classify Menstrual Disorders– Explain characteristics of the different menstrual
disorders– Demonstrate ability to diagnose menstrual
disorders– Apply Knowledge and skills acquired to manage
menstrual disorders.
Division of Reproductive Health
Definition of normal menstruation
• It is the cyclical shading of a functional endometrium; and has the following characteristics:
• Amount of flow: 25-80 ml average 30 mls
• Cycle length: 21-35 days
• Duration of flow: 2-7 days
• Healthy menstrual blood does NOT coagulate
• It occurs in a cyclic manner and regularly
Division of Reproductive Health
Classification of menstrual disorders
• Premenstrual syndrome (PMS)• Mastodynia• Abnormal bleeding due to gynecologic and non
gynecologic disorders:– Amenorrhea, oligomenorhea, hypomenorrhea,
menorrhagia, polymenorrhea, metrorrhagia, etc
• Dysmenorrhoea• Dysfunctional uterine bleeding (DUB)• Post menopausal bleeding
Division of Reproductive Health
Premenstrual syndrome:• occurs in at least 3 consecutive menstrual cycles
• Symptoms must occur in the 2nd half of the menstrual cycle (luteal phase)
• There must be a symptom free period of at least 7 days in the 1st half of the cycle
• Symptoms must be severe enough to require medical advise or treatment e.g. oedema, weight gain, restlessness, irritability and increased tension.
Division of Reproductive Health
Premenstrual syndrome cont’d:
Symptoms include:
• Mood symptoms ( irritability, mood swings, depression, anxiety)
• Physical symptoms ( bloating, breast tenderness, insomnia, fatigue, hot flushes, appetite change, e.t.c)
• Cognitive changes (confusion and poor concentration)
Division of Reproductive Health
PMS -Diagnosis
• Mainly based on patient’s history
• Patient charts symptoms for at least 3 symptomatic cycles
• Rule out medical conditions that mimic PMS e.g. thyroid disease and anemia.
Division of Reproductive Health
PMS- Management( Conservative)
• Diet: (limit caffeine, alcohol, tobacco and chocolate intake; eat small frequent meals
• Decrease sodium intake
• Stress management;
• Aerobic exercises
• Cognitive behavioral therapy
Division of Reproductive Health
PMS management(Drug therapy)
• Calcium carbonate (for bloating, pain and food cravings)
• Magnesium ( for water retention)
• Vitamin B6 and vitamin E
• NSAIDs
• Bromocryptine for mastalgia
Division of Reproductive Health
Mastodynia
• Also termed mastalgia
• Defined as: intolerable breast pain during the second half of the menstrual cycle.
• caused by edema and engorgement of the vascular and ductal systems
• Occurs cyclically in the luteal phase
Division of Reproductive Health
Mastodynia -diagnosis
• History and examination
• Can be confirmed by aspiration
• Ultrasound
• Serial mammography
• Excisional biopsy sometimes is necessary
• Rule out: Mastitis, neoplasm
Division of Reproductive Health
Mastodynia- treatment
• Breast support• Avoid- coffee, tea, chocolate, cola drinks• Avoid nicotine• May occasionally use a mild diuretic• Drug therapy: topical NSAIDS, Gosarelin
(Zoladex), • Limited success with: tamoxifen, danazol,
bromocryptine, oral contraceptives, vitamins
Division of Reproductive Health
Menorrhagia (Hypermenorrhea)
• Defined as excessive, heavy or prolonged menstrual flow
• Possible causes include: submucous myomas, adenomyosis, IUDs, endometrial hyperplasia, malignant tumors e.t.c
Division of Reproductive Health
Hypomenorrhea (cryptomenorrhea)
• Defined as unusually light menstrual flow sometimes only spotting
• Possible causes include: hymenal or cervical stenosis, uterine synechiae (Asherman’s syndrome), occasionally oral contraceptives
Division of Reproductive Health
Metrorrhagia (intermenstrual bleeding)
• Defined as bleeding occurring any time between the menstrual periods
• Possible causes include: endometrial polyps, CA cervix, CA endometrium, exogenous estrogen administration
Division of Reproductive Health
Polymenorrhea
• Describes periods that occur too frequently
• Usually associated with anovulation and rarely with a shortened luteal phase in the menstrual cycle
Division of Reproductive Health
Menometrorhagia
• This is bleeding that occurs at irregular intervals and varies in amount and duration of bleeding
• Caused by any condition that can lead to intermenstrual bleeding
Division of Reproductive Health
Oligomenorrhea
• Describes menstrual periods that occur more than 35 days apart
• Possible causes: anovulation which may be from endocrine causes (pregnancy, menopause, pituitary and hypothalamic disorders); or systemic causes (excessive weight loss); estrogen secreting tumors etc
Division of Reproductive Health
AMENORRHEA• No menstrual period for more than 6 months
• Possible causes:
- Congenital uterine absence
- Hormonal disturbances from the hypothalamus and pituitary gland
- Failure of the ovary to receive or maintain egg cells
- Genetic diseases e.g. causes of intersex i.e. 5-alpha-reductase deficiency
Division of Reproductive Health
Diagnosis in abnormal uterine bleeding
• History and physical examination• Cytological examination –include biopsy and
histology• Pelvic ultrasound scan• Endometrial biopsy• Hysteroscopy• Dilatation and curettage• Hormonal profile• Blood tests- Haemogram, thyroid function tests e.t.c.
Division of Reproductive Health
Management of abnormal uterine bleeding- principles
• Treat cause appropriately
May include
• Hormonal preparations
• Surgery
• Endometrial ablation and endometrial resection, Prostaglandin synthetase inhibitors,
• Levonogestrel releasing IUDs
Division of Reproductive Health
Dysmenorrhea
• Definition: Pain associated with menstruation• Risk factors:
– Menstrual factors (early menarche, menorrhagia)
– Parity (lower in multipara)
– Diet (reduced intake of fish, eggs and fruits)
– Exercise (reduces dysmenorrhoea)
– Cigarette smoking (increases)
– Psychological (emotionally dependent and overprotected girls, family history,)
Division of Reproductive Health
Dysmenorrhea- classification• Primary or spasmodic dysmenorrhea:
– Essential/ intrinsic / functional. Defined as painful menstruation in absence of pelvic pathology
– Usually starts at puberty
– Follows onset of ovulation and presents throughout period of bleeding.
• Congestive or secondary dysmenorrhea:– Underlying pelvic disease e.g. uterine abnormalities,
infections, endometriosis, foreign bodies, iatrogenic
• Membranous dysmenorrhea: – associated with passage of endometrial cast through an
undilated cervix.
Division of Reproductive Health
Dysmenorhea- clinical features• Primary Dysmenorhea:
– Age: Usually seen among younger women– Time of onset: 2-3 yrs after menarche– Duration of pain: starts just prior to menses, lasts
about 2 days– Type of pain: cramping pain
• Membranous Dysmenorhea:– Intense cramping pain associated with passage of
an endometrial cast through an undilated cervix.
Division of Reproductive Health
Dysmenorhea- clinical features (ctd)
• Secondary Dysmenorhea:- Associated with specific diseases and disorders e.g.
PID, Uterine fibroids, endometriosis etc– Usually among older women (3rd to 4th decade)– Time of onset: follows initial years of normal
painless cycles– Duration of pain: Onset is few days prior to
menses and continues throughout cycle even after cessation of menses
– Type of pain: continuous dull aching or dragging pain
Division of Reproductive Health
Dysmenorhea -managementDysmenorhea
Assurance
Laxatives
Analgesics and Antispasmodics
Fails
Contraception not required or OC pills contraindicated
Contraception required or NSAIDS contra indicated
Prostaglandin synthetase inhibitors OC pills Fails
Laparoscopy to look for causes of secondary Dysmenorhea
No cause found but persistent and severe pain
Cause found
Surgery Treat as appropriate
Division of Reproductive Health
Dysfunctional Uterine bleeding (DUB)
• Defined as a symptom complex that includes any condition of abnormal uterine bleeding in the absence of pathologic cause
• Commonly caused by anovulation as seen in polycystic ovarian disease and obesity
• May occur in all age groups from prepubertal girls to menopausal women
Division of Reproductive Health
DUB management
• Medical management:– NSAIDS– Antifibrinolytic agents– Hormones
• Surgical– Endometrial resection– Endometrial ablation– hysterectomy
Division of Reproductive Health
Postmenopausal bleeding
• Any vaginal bleeding in a postmenopausal women should be considered abnormal
• Frequently associated with malignancies of the reproductive tract
• Benign causes include: endometrial /cervical polyps, trauma, senile vaginitis, vulval dystrophies
• Management depends on the cause.