Menstrual disorders Mrs. Mahdia Shaker RN, RM, APN.
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Transcript of Menstrual disorders Mrs. Mahdia Shaker RN, RM, APN.
Menstrual disordersMenstrual disorders
Mrs. Mahdia ShakerMrs. Mahdia Shaker
RN, RM, APN.RN, RM, APN.
Amenorrhea Amenorrhea
Absence of menses during the reproductive year's Absence of menses during the reproductive year's categories of amenorrhea:- categories of amenorrhea:-
categories of amenorrhea:-categories of amenorrhea:-A: Primary amenorrheaA: Primary amenorrhea: is defined as:-: is defined as:-- Absence of menses by age 14 with absence of - Absence of menses by age 14 with absence of
growth and development of secondary sexual growth and development of secondary sexual chch.chch.
- Absence of menses by age 16 with normal - Absence of menses by age 16 with normal development of secondary sexual chch.development of secondary sexual chch.
B: secondary amenorrheaB: secondary amenorrhea: : is the absence of is the absence of menses for 3 cycles or 6 months in women who menses for 3 cycles or 6 months in women who have previously menstruated regularly.have previously menstruated regularly.
EtiologyEtiology
EtiologyEtiology
Causes of primary amenorrhea:Causes of primary amenorrhea:1- Extreme wt gain or loss.1- Extreme wt gain or loss.2- Congenial abnormalities of the 2- Congenial abnormalities of the
reproductive system.reproductive system.3- Stress from a major life event.3- Stress from a major life event.4- Excessive exercises4- Excessive exercises5- Eating disorders (anorexia nervosa)5- Eating disorders (anorexia nervosa)6- Polycystic ovarian syndrome.6- Polycystic ovarian syndrome.7- Hypothyroidism.7- Hypothyroidism.
Causes of primary Causes of primary amenorrhea:amenorrhea:
8- Turner syndrome.8- Turner syndrome.
9- Imperforated hymen.9- Imperforated hymen.
10- Chronic illness10- Chronic illness
11- Pregnancy.11- Pregnancy.
12- Cystic fibrosis.12- Cystic fibrosis.
13- Congenial heart disease.13- Congenial heart disease.
14- Ovarian or adrenal tumors.14- Ovarian or adrenal tumors.
Causes of secondary Causes of secondary amenorrheaamenorrhea
Breast feedingBreast feeding Emotional stressEmotional stress Mal nutritionMal nutrition PregnancyPregnancy Pituitary, ovarian, or adrenal turnersPituitary, ovarian, or adrenal turners DepressionDepression Hyper thyroid or hypothermiaHyper thyroid or hypothermia Mal nutritionMal nutrition
Causes of secondary Causes of secondary amenorrheaamenorrhea
Hyper prolactinemiaHyper prolactinemia Rapid wt gain or lossRapid wt gain or loss Chemotherapy or radiotherapyChemotherapy or radiotherapy Vigorous excreteVigorous excrete Kidney failureKidney failure ColitisColitis Tranquilizers or antidepressant Tranquilizers or antidepressant Post partum pituitary necrosis Post partum pituitary necrosis Early menopause Early menopause
Assessment:Assessment:
history of etiologic factorshistory of etiologic factors physical examination for:physical examination for:
1.1. nutritional statusnutritional status
2.2. Wt. & Ht. and vital signs Wt. & Ht. and vital signs
3.3. Anorexia nervosa( hypothermia. Anorexia nervosa( hypothermia. Bradycardia, hypotension, and reduced Bradycardia, hypotension, and reduced subcutaneous fat)subcutaneous fat)
4.4. Androgen excess: facial hair and acne.Androgen excess: facial hair and acne.
5.5. Delayed puberty: absence of facial and Delayed puberty: absence of facial and axillary hairaxillary hair
Assessment:Assessment: laboratory tests:laboratory tests:1.1. U/S U/S 2.2. Pregnancy testPregnancy test3.3. Thyroid function testThyroid function test4.4. Prolactine levelProlactine level5.5. If high level of FSH: indicate ovarian If high level of FSH: indicate ovarian
failurefailure6.6. If high level of LH: indicate gonadal If high level of LH: indicate gonadal
dysfunctiondysfunction7.7. LaprascopyLaprascopy8.8. CTCT
Treatment:Treatment: depend on the depend on the cause: cause:
In primary amenorrhea:In primary amenorrhea: correct the underlying causecorrect the underlying cause estrogen replacement therapy estrogen replacement therapy if pituitary tumor: treatement with if pituitary tumor: treatement with
surgical resection, radiation and drug surgical resection, radiation and drug therapytherapy
surgery to correct abnormalities of surgery to correct abnormalities of genital tractgenital tract
Therapeutic intervention Therapeutic intervention for secondary amenorrhea:for secondary amenorrhea:Therapeutic intervention for Therapeutic intervention for
secondary amenorrhea:secondary amenorrhea: Cyclic progesteroneCyclic progesterone Promocriptine to treat Promocriptine to treat
hyperprolactinemiahyperprolactinemia GnRH. When the cause is GnRH. When the cause is
hypothalamic failure hypothalamic failure thyroid hormone replacementthyroid hormone replacement
Nursing intervention:Nursing intervention:
counseling and educationcounseling and education adres the diverse causes of amenorrhea, adres the diverse causes of amenorrhea,
the relationship to sexual identity, possible the relationship to sexual identity, possible infertilityinfertility
inform the woman about the purpose of inform the woman about the purpose of each diagnostic testeach diagnostic test
sensitive listening, interviewing, and sensitive listening, interviewing, and presenting treatement optionspresenting treatement options
Nutritional counseling Nutritional counseling Emphasize healthy life styleEmphasize healthy life style
Teaching guidelines for Teaching guidelines for maintaining healthy life style:maintaining healthy life style:
balance energy expenditure with energy balance energy expenditure with energy intakeintake
modify diet to maintain ideal Wtmodify diet to maintain ideal Wt avoid excessive use of alcohol and mood-avoid excessive use of alcohol and mood-
altering or sedative drugsaltering or sedative drugs Avid cigarette smokingAvid cigarette smoking Identify areas emotional stress and seek Identify areas emotional stress and seek
assistance to resolve themassistance to resolve them Balance work, recreation, and restBalance work, recreation, and rest
Teaching guidelines for Teaching guidelines for maintaining healthy life style:maintaining healthy life style:
Maintain a positive outlook regarding the Maintain a positive outlook regarding the diagnosis and prognosisdiagnosis and prognosis
Participate in ongoing care to monitor Participate in ongoing care to monitor replacement therapy or associated replacement therapy or associated conditions.conditions.
Maintain bone density through:Maintain bone density through:– calcium intake( 1,200-1.5 mg or more daily)calcium intake( 1,200-1.5 mg or more daily)– weight-bearing exercise(30 minutes or more weight-bearing exercise(30 minutes or more
daily)daily)– hormone replacement therapyhormone replacement therapy
DysmenorrheaDysmenorrhea
Etiology:Etiology: Primary dysmenorrhea: caused by increased Primary dysmenorrhea: caused by increased
prostaglandin production by the prostaglandin production by the endometrium in an ovulatory cycle which endometrium in an ovulatory cycle which cause contraction of the uterus. The highest cause contraction of the uterus. The highest level is in the first 2 days of menses.level is in the first 2 days of menses.
Secondary dysmenorrhea: is painful Secondary dysmenorrhea: is painful menstruation due to pelvic or uterine menstruation due to pelvic or uterine pathology. pathology.
Causes of Secondary Causes of Secondary dysmenorrheadysmenorrhea
Endometriosis: ectopic implantation of the Endometriosis: ectopic implantation of the endometrial tissue in other parts of the endometrial tissue in other parts of the pelvic, it’s the most common cause of pelvic, it’s the most common cause of dysmenorrheadysmenorrhea
Adenomiosis: ingrowth of the endometrium Adenomiosis: ingrowth of the endometrium into the uterine musculature.into the uterine musculature.
Fibroids Fibroids Pelvic infectionPelvic infection Intrauterine device Intrauterine device Cervical stenosisCervical stenosis Congenital uterine or vaginal abnormalitiesCongenital uterine or vaginal abnormalities
Clinical manifestationClinical manifestation sharp, intermittent spasm, usually in subrapupic sharp, intermittent spasm, usually in subrapupic
area.area. pain may radiate to the back of the leg or the pain may radiate to the back of the leg or the
lower backlower back systemic symptoms:systemic symptoms:1.1. nausea nausea 2.2. vomitingvomiting3.3. diarrheadiarrhea4.4. fatiguefatigue5.5. feverfever6.6. Headache or dizzinessHeadache or dizziness
Assessment:Assessment: Focused history and physical examination:Focused history and physical examination:1.1. in primary dysmenorrhea:in primary dysmenorrhea: cramping cramping
pain with menstruation and the physical pain with menstruation and the physical examination is completely normalexamination is completely normal
2.2. in secondary dysmenorrhea:in secondary dysmenorrhea: the history the history discloses cramping pain starting after 25 discloses cramping pain starting after 25 years old with pelvic abnormality.years old with pelvic abnormality.– history of infertilityhistory of infertility– heavy menstrual flowheavy menstrual flow– irregular cyclesirregular cycles– little or no response to NSAIDslittle or no response to NSAIDs
Assessment:Assessment:
3.3. detailed sexual history to asses for inflammation detailed sexual history to asses for inflammation or scaringor scaring
4.4. bimanual pelvic examination in nonmenstrual bimanual pelvic examination in nonmenstrual phase of the cyclephase of the cycle
5.5. laboratory tests for: laboratory tests for: CBC to R/O anemiaCBC to R/O anemia Urine analysis to R/O bladder infectionUrine analysis to R/O bladder infection Pregnancy testPregnancy test Cervical culture to exclude STICervical culture to exclude STI ESR to detect an inflammatory processESR to detect an inflammatory process Pelvic and vaginal U/S Pelvic and vaginal U/S Diagnostic laprascopy or lapratomyDiagnostic laprascopy or lapratomy
Treatement:Treatement:
pain relief : NSAIDs, cyclooxygenase- 2 pain relief : NSAIDs, cyclooxygenase- 2 inhibitorinhibitor
hormonal contraceptives hormonal contraceptives life style changes:life style changes: daily ex.daily ex. limit salty foodslimit salty foods wt. losswt. loss smoking cessationsmoking cessation rekaxation techniquesrekaxation techniques
Dysfunctional uterine Dysfunctional uterine bleedingbleeding
is irregular, abnormal bleeding that is not caused by is irregular, abnormal bleeding that is not caused by pregnancy, a tumor or infectionpregnancy, a tumor or infection
( Bardeley, 2005). ( Bardeley, 2005).
It occurs frequently at the beginning of and end of their It occurs frequently at the beginning of and end of their reproductive years.reproductive years.
With anovulation, estrogen levels rise as usual in the With anovulation, estrogen levels rise as usual in the early phase of the menstrual cycle. In absence of early phase of the menstrual cycle. In absence of ovulation, a corpus luteum never forms and ovulation, a corpus luteum never forms and progesterone in not produced. The endometrium progesterone in not produced. The endometrium moves into a hyperproliferative state, this lead to moves into a hyperproliferative state, this lead to irregular sloughing of the endometrium and excessive irregular sloughing of the endometrium and excessive bleeding.bleeding.
Types of uterine bleeding Types of uterine bleeding disordersdisorders
Amenorrhea: (absence of menstruation)Amenorrhea: (absence of menstruation) Hypomenorrhea: (scanty menstruation)Hypomenorrhea: (scanty menstruation) Oligomenorrhea: (infrequent Oligomenorrhea: (infrequent
menstruation, periods more than 35 days menstruation, periods more than 35 days apart), Menorrhagia: (excessive apart), Menorrhagia: (excessive menstruation),menstruation),
Metrorrhagia: (bleeding between periods). Metrorrhagia: (bleeding between periods). Menometrorrhagia: (is heavy bleeding Menometrorrhagia: (is heavy bleeding
during and between menstrual periods).during and between menstrual periods).
Etiology:Etiology:
adenomiosisadenomiosis pregnancypregnancy hormonal imbalancehormonal imbalance fibroid tumorsfibroid tumors endometrial polyps or cancerendometrial polyps or cancer EndometriosisEndometriosis
Etiology:Etiology:
IUCDIUCD Polysystic ovary syndromePolysystic ovary syndrome Morbid obesityMorbid obesity Steroid therapySteroid therapy HypothyroidismHypothyroidism Clotting disordersClotting disorders
Clinical manifestation: Clinical manifestation: vaginal bleeding between periodsvaginal bleeding between periods irregular menstrual cycleirregular menstrual cycle infertilityinfertility mood swingsmood swings hot flasheshot flashes vaginal tendernessvaginal tenderness menstrual flow either scanty or profusemenstrual flow either scanty or profuse obesityobesity acneacne diabetes: insulin resistance is commondiabetes: insulin resistance is common
Assessment: Assessment: history takinghistory taking assist in pelvic examination to identify any assist in pelvic examination to identify any
structural abnormalitiesstructural abnormalities laboratory tests:laboratory tests:1.1. CBC to reveal anemiaCBC to reveal anemia2.2. PT to detect blood disordersPT to detect blood disorders3.3. BHCG to rule out abortion or ectopic pregnancyBHCG to rule out abortion or ectopic pregnancy4.4. TSH to screens for hypothyroidismTSH to screens for hypothyroidism Transvaginal ultrasound to measure endometrium Transvaginal ultrasound to measure endometrium Pelvic ultrasoundPelvic ultrasound Endometrial biopsy to check intrauterine Endometrial biopsy to check intrauterine
pathologypathology D&C for diagnostic evaluationD&C for diagnostic evaluation
Treatment: Treatment:
it depend on the cause and age of the clientit depend on the cause and age of the client medical care with pharmacotherapy:medical care with pharmacotherapy:
1.1. estrogen: cause vasospasm of the uterine estrogen: cause vasospasm of the uterine arteries to decrease bleedingarteries to decrease bleeding
2.2. cyclic progesterone or long acting cyclic progesterone or long acting progesterone progesterone
3.3. oral contraceptives: regulate the cycle and oral contraceptives: regulate the cycle and suppress the endometriumsuppress the endometrium
4.4. NSAIDs inhibit prostaglandin NSAIDs inhibit prostaglandin
5.5. Iron replacement Iron replacement
Treatment:Treatment:
if the client doesn’t respond to if the client doesn’t respond to medical therapy:medical therapy:
1.1. D&CD&C
2.2. Endometrial ablation: is an Endometrial ablation: is an alternative to hysterectomyalternative to hysterectomy
3.3. Thermal balloon to ablate the Thermal balloon to ablate the endometriumendometrium
Nursing management:Nursing management:
Educate the client about normal Educate the client about normal menstrual cycle and the possible menstrual cycle and the possible causes for her abnormal patterncauses for her abnormal pattern
Inform the woman about treatment Inform the woman about treatment optionoption
Inform her about any prescribed Inform her about any prescribed medicationmedication
Don’t simply encourage the woman Don’t simply encourage the woman to “live with it”. to “live with it”.
Nursing management:Nursing management:
It may result in the following It may result in the following complication:complication:
1.1. infertility from lack of ovulationinfertility from lack of ovulation
2.2. anemia from prolonged bleedinganemia from prolonged bleeding
3.3. endometrial cancer from prolonged build endometrial cancer from prolonged build up of the endometrial lining without up of the endometrial lining without menstrual bleedingmenstrual bleeding
Adequate follow up and evaluation is Adequate follow up and evaluation is necessarynecessary
Premenstrual syndrome Premenstrual syndrome ( PMS( PMS))
The The premenstrual syndrome premenstrual syndrome (PMS) is a distinct (PMS) is a distinct clinical entity characterized by a cluster of clinical entity characterized by a cluster of physical and psychological symptoms limited physical and psychological symptoms limited to 3 to 14 days preceding menstruation and to 3 to 14 days preceding menstruation and relieved by onset of the menses. relieved by onset of the menses.
The incidence of PMS seems to increase with The incidence of PMS seems to increase with age. It is less common in women in their teens age. It is less common in women in their teens and 20s, and most of the women seeking help and 20s, and most of the women seeking help for the problem are in their mid-30s. for the problem are in their mid-30s.
Although the causes of PMS are poorly Although the causes of PMS are poorly documented, they probably are multifactorial. documented, they probably are multifactorial.
Clinical manifestation:Clinical manifestation:
The physical symptoms of PMS include:The physical symptoms of PMS include:– Painful and swollen breastsPainful and swollen breasts– Bloating, abdominal painBloating, abdominal pain– Headache Headache – Backache Backache
Psychologically, there may be:Psychologically, there may be:o DepressionDepressiono AnxietyAnxietyo IrritabilityIrritabilityo Behavioral changes.Behavioral changes.
Premenstrual dysphoric Premenstrual dysphoric disorder:disorder:
Is a psychiatric diagnosis that has Is a psychiatric diagnosis that has been developed to distinguish been developed to distinguish women whose symptoms are severe women whose symptoms are severe enough to interfere significantly with enough to interfere significantly with activities of daily living or in whom activities of daily living or in whom the symptoms are not relieved with the symptoms are not relieved with the onset of menstruation, as is the onset of menstruation, as is usually the case with PMS. usually the case with PMS.
ASSESSMENT: ASSESSMENT: Diagnosis focuses on identification of the symptom Diagnosis focuses on identification of the symptom
clusters by means of prospective charting for at clusters by means of prospective charting for at least 3 months.least 3 months.
A complete history and physical examination are A complete history and physical examination are necessary to exclude other physical causes of the necessary to exclude other physical causes of the symptoms.symptoms.
Depending on the symptom pattern, blood studies, Depending on the symptom pattern, blood studies, including:including:
Thyroid hormonesThyroid hormones Glucose tests may be done.Glucose tests may be done. Psychosocial evaluation is helpful to exclude Psychosocial evaluation is helpful to exclude
emotional illness that is merely exacerbated emotional illness that is merely exacerbated premenstrually.premenstrually.
TREATMENT:TREATMENT:
Lifestyle changes: Lifestyle changes: – An integrated program of regular exercise 3-5 An integrated program of regular exercise 3-5
times each week.times each week.– Reduce stressReduce stress– avoidance of caffeineavoidance of caffeine– A diet emphasizing complex carbohydrates A diet emphasizing complex carbohydrates
and increase water intake. Foods high in and increase water intake. Foods high in simple sugars should be avoided simple sugars should be avoided
– Limit intake of alcohol.Limit intake of alcohol.– Stop smokingStop smoking
TREATMENT:TREATMENT:
Vitamins and mineral supplements:Vitamins and mineral supplements:
1.1. Multivitamin dailyMultivitamin daily
2.2. Vitamin E,400units dailyVitamin E,400units daily
3.3. Calcium, 1,200mg dailyCalcium, 1,200mg daily
4.4. Magnesium, 200-400mg daily Magnesium, 200-400mg daily
TREATMENT:TREATMENT:
Drug therapy should be used cautiously:Drug therapy should be used cautiously:
1.1. NSAIDs taken a week prior to NSAIDs taken a week prior to mensesmenses
2.2. Oral contraceptives ( low doses)Oral contraceptives ( low doses)
3.3. AntidepressantsAntidepressants
4.4. Anxiolytics Anxiolytics
5.5. DiureticsDiuretics