Menstrual disorders

Amenorrhea
Absence of menses during the reproductive year's
categories of amenorrhea:-
categories of amenorrhea:-
A: Primary amenorrhea: is defined as:-
- Absence of menses by age 14 with absence of growth
and development of secondary sexual chch.
- Absence of menses by age 16 with normal development
of secondary sexual chch.
B: secondary amenorrhea: is the absence of menses for
3 cycles or 6 months in women who have previously
menstruated regularly.


Etiology
Etiology
Causes of primary amenorrhea:
1- Extreme wt gain or loss.
2- Congenial abnormalities of the reproductive
system.
3- Stress from a major life event.
4- Excessive exercises
5- Eating disorders (anorexia nervosa)
6- Polycystic ovarian syndrome.
7- Hypothyroidism.
Causes of primary amenorrhea:

8- Turner syndrome.
9- Imperforated hymen.
10- Chronic illness
11- Pregnancy.
12- Cystic fibrosis.
13- Congenial heart disease.
14- Ovarian or adrenal tumors.
Causes of secondary
amenorrhea
Breast feeding
Emotional stress
Mal nutrition
Pregnancy
Pituitary, ovarian, or adrenal turners
Depression
Hyper thyroid or hypothermia
Mal nutrition

Causes of secondary
amenorrhea
Hyper prolactinemia
Rapid wt gain or loss
Chemotherapy or radiotherapy
Vigorous excrete
Kidney failure
Colitis
Tranquilizers or antidepressant
Post partum pituitary necrosis
Early menopause
Assessment:
history of etiologic factors
physical examination for:
1. nutritional status
2. Wt. & Ht. and vital signs
3. Anorexia nervosa( hypothermia. Bradycardia,
hypotension, and reduced subcutaneous fat)
4. Androgen excess: facial hair and acne.
5. Delayed puberty: absence of facial and axillary
hair
Assessment:
laboratory tests:
1. U/S
2. Pregnancy test
3. Thyroid function test
4. Prolactine level
5. If high level of FSH: indicate ovarian failure
6. If high level of LH: indicate gonadal
dysfunction
7. Laprascopy
8. CT
Treatment: depend on the cause:
In primary amenorrhea:
correct the underlying cause
estrogen replacement therapy
if pituitary tumor: treatement with surgical
resection, radiation and drug therapy
surgery to correct abnormalities of genital
tract
Therapeutic intervention for
secondary amenorrhea:
Therapeutic intervention for secondary
amenorrhea:
Cyclic progesterone
Promocriptine to treat
hyperprolactinemia
GnRH. When the cause is hypothalamic
failure
thyroid hormone replacement

Intervention:
counseling and education
adres the diverse causes of amenorrhea, the
relationship to sexual identity, possible infertility
inform the woman about the purpose of each
diagnostic test
sensitive listening, interviewing, and presenting
treatement options
Nutritional counseling
Emphasize healthy life style
Teaching guidelines for maintaining
healthy life style:
balance energy expenditure with energy intake
modify diet to maintain ideal Wt
avoid excessive use of alcohol and mood-altering
or sedative drugs
Avid cigarette smoking
Identify areas emotional stress and seek assistance
to resolve them
Balance work, recreation, and rest
Teaching guidelines for maintaining
healthy life style:
Maintain a positive outlook regarding the
diagnosis and prognosis
Participate in ongoing care to monitor
replacement therapy or associated conditions.
Maintain bone density through:
calcium intake( 1,200-1.5 mg or more daily)
weight-bearing exercise(30 minutes or more daily)
hormone replacement therapy
Dysmenorrhea
Etiology:
Primary dysmenorrhea: caused by increased
prostaglandin production by the endometrium in an
ovulatory cycle which cause contraction of the
uterus. The highest level is in the first 2 days of
menses.

Secondary dysmenorrhea: is painful menstruation
due to pelvic or uterine pathology.

Causes of Secondary dysmenorrhea
Endometriosis: ectopic implantation of the
endometrial tissue in other parts of the pelvic,
its the most common cause of dysmenorrhea
Adenomiosis: ingrowth of the endometrium into
the uterine musculature.
Fibroids
Pelvic infection
Intrauterine device
Cervical stenosis
Congenital uterine or vaginal abnormalities
Clinical manifestation
sharp, intermittent spasm, usually in subrapupic area.
pain may radiate to the back of the leg or the lower
back
systemic symptoms:
1. nausea
2. vomiting
3. diarrhea
4. fatigue
5. fever
6. Headache or dizziness
Assessment:
Focused history and physical examination:
1. in primary dysmenorrhea: cramping pain
with menstruation and the physical
examination is completely normal
2. in secondary dysmenorrhea: the history
discloses cramping pain starting after 25 years
old with pelvic abnormality.
history of infertility
heavy menstrual flow
irregular cycles
little or no response to NSAIDs
Assessment:
3. detailed sexual history to asses for inflammation or
scaring
4. bimanual pelvic examination in nonmenstrual phase of
the cycle
5. laboratory tests for:
CBC to R/O anemia
Urine analysis to R/O bladder infection
Pregnancy test
Cervical culture to exclude STI
ESR to detect an inflammatory process
Pelvic and vaginal U/S
Diagnostic laprascopy or lapratomy
Treatement:
pain relief : NSAIDs, cyclooxygenase- 2 inhibitor
hormonal contraceptives
life style changes:
daily ex.
limit salty foods
wt. loss
smoking cessation
rekaxation techniques
Dysfunctional uterine bleeding
is irregular, abnormal bleeding that is not caused by
pregnancy, a tumor or infection
( Bardeley, 2005).
It occurs frequently at the beginning of and end of their
reproductive years.
With anovulation, estrogen levels rise as usual in the early
phase of the menstrual cycle. In absence of ovulation, a
corpus luteum never forms and progesterone in not
produced. The endometrium moves into a hyperproliferative
state, this lead to irregular sloughing of the endometrium
and excessive bleeding.
Types of uterine bleeding
disorders
Amenorrhea: (absence of menstruation)
Hypomenorrhea: (scanty menstruation)
Oligomenorrhea: (infrequent menstruation,
periods more than 35 days apart),
Menorrhagia: (excessive menstruation),
Metrorrhagia: (bleeding between periods).
Menometrorrhagia: (is heavy bleeding during
and between menstrual periods).
Etiology:
adenomiosis
pregnancy
hormonal imbalance
fibroid tumors
endometrial polyps or cancer
Endometriosis

Etiology:
IUCD
Polysystic ovary syndrome
Morbid obesity
Steroid therapy
Hypothyroidism
Clotting disorders

Clinical manifestation:
vaginal bleeding between periods
irregular menstrual cycle
infertility
mood swings
hot flashes
vaginal tenderness
menstrual flow either scanty or profuse
obesity
acne
diabetes: insulin resistance is common
Assessment:
history taking
assist in pelvic examination to identify any structural
abnormalities
laboratory tests:
1. CBC to reveal anemia
2. PT to detect blood disorders
3. BHCG to rule out abortion or ectopic pregnancy
4. TSH to screens for hypothyroidism
Transvaginal ultrasound to measure endometrium
Pelvic ultrasound
Endometrial biopsy to check intrauterine pathology
D&C for diagnostic evaluation
Treatment:
it depend on the cause and age of the client
medical care with pharmacotherapy:
1. estrogen: cause vasospasm of the uterine
arteries to decrease bleeding
2. cyclic progesterone or long acting progesterone
3. oral contraceptives: regulate the cycle and
suppress the endometrium
4. NSAIDs inhibit prostaglandin
5. Iron replacement
Treatment:
if the client doesnt respond to medical
therapy:
1. D&C
2. Endometrial ablation: is an alternative to
hysterectomy
3. Thermal balloon to ablate the
endometrium
Management:
Educate the client about normal
menstrual cycle and the possible causes
for her abnormal pattern
Inform the woman about treatment
option
Inform her about any prescribed
medication
Dont simply encourage the woman to
live with it.
Nursing management:
It may result in the following complication:
1. infertility from lack of ovulation
2. anemia from prolonged bleeding
3. endometrial cancer from prolonged build up
of the endometrial lining without
menstrual bleeding
Adequate follow up and evaluation is
necessary
Premenstrual syndrome ( PMS)
The premenstrual syndrome (PMS) is a distinct
clinical entity characterized by a cluster of
physical and psychological symptoms limited to
3 to 14 days preceding menstruation and
relieved by onset of the menses.
The incidence of PMS seems to increase with
age. It is less common in women in their teens
and 20s, and most of the women seeking help
for the problem are in their mid-30s.
Although the causes of PMS are poorly
documented, they probably are multifactorial.
Clinical manifestation:
The physical symptoms of PMS include:
Painful and swollen breasts
Bloating, abdominal pain
Headache
Backache
Psychologically, there may be:
o Depression
o Anxiety
o Irritability
o Behavioral changes.
Premenstrual dysphoric disorder:
Is a psychiatric diagnosis that has been
developed to distinguish women whose
symptoms are severe enough to interfere
significantly with activities of daily living or
in whom the symptoms are not relieved
with the onset of menstruation, as is
usually the case with PMS.
ASSESSMENT:
Diagnosis focuses on identification of the symptom
clusters by means of prospective charting for at least 3
months.
A complete history and physical examination are
necessary to exclude other physical causes of the
symptoms.
Depending on the symptom pattern, blood studies,
including:
Thyroid hormones
Glucose tests may be done.
Psychosocial evaluation is helpful to exclude emotional
illness that is merely exacerbated premenstrually.
TREATMENT:
Lifestyle changes:
An integrated program of regular exercise 3-5 times
each week.
Reduce stress
avoidance of caffeine
A diet emphasizing complex carbohydrates and
increase water intake. Foods high in simple sugars
should be avoided
Limit intake of alcohol.
Stop smoking
TREATMENT:
Vitamins and mineral supplements:
1. Multivitamin daily
2. Vitamin E,400units daily
3. Calcium, 1,200mg daily
4. Magnesium, 200-400mg daily
TREATMENT:
Drug therapy should be used cautiously:
1. NSAIDs taken a week prior to menses
2. Oral contraceptives ( low doses)
3. Antidepressants
4. Anxiolytics
5. Diuretics