MENSTRUAL CONDITIONS

MENOPAUSE Is described as the normal physiologic cessation of menses Marks the end of a woman’s reproductive capacity PATHOPHYSIOLOGY/ETIOLOGY Is caused by failing ovarian function and decreased estrogen production by the ovary Climacteric is the transition period(perimenopausal) during which the woman’s reproductive function gradually diminishes and disappears. Usually occurs at about age 50.

CLINICAL MANIFESTATIONS ______________is usually the first sign!!! Genitalia-atrophy of vulva, vagina, urethra results in dryness, bleeding, itching, burning, dysuria, thinning of pubic hair, loss of labia minora, decreased lubrication Sexual Function- dyspareunia, decreased intensit and duration of sexual response, but can still have active function Vasomotor-60-70% of women experience “hot flashes”, which may be preceeded by an anxious feeling and accompanied by sweating

Menopause- Clinical Manifestations Con’t. Osteoporosis- decreased bone mass results in increased hip fractures and spinal compression fractures Cardiovascular- increased CAD, cholesterol level, and palpitations may occur Psychological-insomnia, irritability, anxiety, memory loss, fear, and depression

Diagnostic Evaluation-Menopause Hormone levels of LH and FSH will be increased Estradiol will be decreased

Menopause-Treatment Estrogen replacement therapy Indicated to reduce symptoms and to prevent osteoporosis and CAD. Topical preparations may be used for atrophic vaginitis Progesterone preparation also given if uterus is intact to prevent endometrial hyperplasia and possible cancer Vaginal lubricants such as Replens to decrease vaginal dryness and dyspareunia Vitamin E and B supplements- to decrease hot flashes Calcium supplements to prevent bone loss ***A woman is considered post menopausal if she has not had a menstrual period for 1 year****

The Menstrual Cycle Is the cyclical pattern of ovarian hormone secretion (___________and _____________) under the control of pituitary hormones(_______________ and _____________________) that results in thickening of the uterine endometrium, ovulation, and menstruation. Cycle length varies among individuals Phases of the Menstrual Cycle-refer to handout

Menstrual Cycle Diagram

Characteristics of Menstruation Range Average Menarche(onset) 9-17 years of age 12.5 years Cycle Length 24-32 days 29 days Flow-duration 1-8 days 3-5 days Flow-amount 10-75 ml 35 ml Menopause-onset 45-55 years of age 47-50

Premenstrual Syndrome (PMS) Is a group of symptoms such as headache, irritability, depression, breast tenderness, and bloating that is clearly related to the onset of menstruation Premenstrual Dysphoric Disorder(PMDD) is a more severe form of PMS

Pathophysiology/ Etiology of PMS Linked to hormonal imbalances , prostaglandins, endorphins, psychological factors such as attitudes and beliefs related to menstruation and environmental factors such as nutrition and pollution Most common in women in their 30’s May occur in 25 to 50% of menstruating women

PMS-Manifestations Symptoms may begin 7 to 14 days before onset of menstrual flow; diminish 1 to 2 days after menses begins Physical- edema of extremities, abdominal fullness, breast swelling and tenderness, headache, vertigo, palpitations, acne, backache, constipation, thirst, weight gain Behavioral-irritability, fatigue, lethargy, depression, anxiety, crying spells Diagnosis is based on clinical manifestations; usually no diagnostic evaluation is necessary

PMS- Management Restrict sodium, caffeine, tobacco, ETOH, an refined sweets Aerobic exercise Vitamin B6 supplements and daily calcium Progesterone replacement therapy Prostaglandin inhibitor Diuretics to decrease fluid retention and weight gain Anxiolytic agents- to decrease anxiety Counseling Oophorectomy usually self-limiting without complications

Dysmenorrhea Dysmenorrhea is painful menstruation PATHOPHYSIOLOGY- Is classified as either primary or secondary PRIMARY-current research supports increased prostaglandin production by the endometrium as the chief cause SECONDARY-Due to a lesion such as endometriosis, pelvic infection, congenital abnormality, uterine fibroids

Dysmenorrhea-Clinical Manifestations Pain may be due to increased uterine contractility and decreased endometrial flow Characteristics of pain-colicky or dull, usually in lower mid-abdominal region, spasmodic or constant May also experience nausea, vomiting, diarrhea, headache, chills, tiredness, nervousness, and low backache

Dysmenorrhea-Diagnostic Evaluation Tests to rule out underlying lesion Chlamydia and Gonorrhea tests- may show infection Pelvic ultrasound- may detect tumor, endometriosis Possibly a hysteroscopy and laparoscopy- primarily to detect endometriosis

Management of Primary Dysmenorrhea Local heat; such as a heating pad to increase blood flow and decrease spasms Exercise to increase endorphin release Nonnarcotic analgesics, especially NSAID’s-ibuprofen for their antiprostaglandin action Oral contraceptives to decrease flow and contractility of the uterus In some cases, D & C may be helpful Usually self-limiting without complications

Amenorrhea Amenorrhea is absence of menstrual flow Pathophysiology- Classified as either Primary or Secondary PRIMARY- Menarche does not occur by age 16 Due to chromosomal, hormonal, nutritional, psychogenic disorders, or pregnancy

Amenorrhea SECONDARY- Menstruation stops for three cycle intervals, or 6 months of amenorrhea in a woman who previously menstruated Some medications such as phenothiazines and oral contraceptives, may also induce amenorrhea May be due to normal pregnancy or lactation, menopause, psychogenic, hormonal, nutritional, or exercise-related disorders Excessive exercise or inadequate nutrition with decreased body fat stores is a significant cause of amenorrhea in young women

Amenorrhea-Diagnostic Evaluation Pregnancy test Hormonal levels- LH and FSH- to detect ovarian failure Prolactin level to rule out pituitary tumor Progesterone challenge test Positive-bleeding occurs-chronic anovulation is most likely Negative-no bleeding occurs- may indicate organ failure- other tests are needed Genetic karyotyping to detect chromosome abnormalities

Amenorrhea- Management Discontinue causative medications Hormonal replacement therapy Nutritional, exercise, or psychological counseling as indicated Recommend decreased exercise in athletes to increase body fat stores and decrease stress ***COMPLICATIONS- It has been theorized that prolonged amenorrhea may lead to changes of the endometrium

Dysfunctional Uterine Bleeding (DUB) DUB is abnormal uterine bleeding that has no organic cause, such as tumor, infection, or pregnancy

DUB- Pathophysiology DUB is frequently caused by immature hypothalmic stimulation in adolescents DUB is caused by anovulation in any age group, especially in teens and perimenopausal women, due to impaired follicular formation or rupture, or corpus luteum dysfunction Ovarian failure in perimenopausal women frequently causes DUB Temporary estrogen withdrawal at ovulation may cause midcycle ovulatorry bleeding Emotional lability, malnutrition, and changes in exercise may cause changes in gonadotropin release ar the hypothalmic level, causing altered menstrual pattern

DUB- Clinical Manifestations Abnormal bleeding may occur in any of the following patterns: Menorrhagia-excessive bleeding during regular menstruation; can be increased in duration or amount Metorrhagia-bleeding from the uterus between regular menstrual periods; significant because it is usually a symptom of disease

DUB- Diagnostic Evaluation Tests are done to rule out pathologic causes of abnormal bleeding Pregnancy test CBC to detect anemia and platelet count and coagulation screen to rule out blood dyscrasia PAP smear to rule out malignancy Thorough exam to rule out trauma or foreign body Chlamydia and gonorrhea test to rule out PID Pelvic ultrasound to rule out ovarian and uterine cysts and tumors Hysteroscopy to detect uterine fibroids, polyps, and other lesions Endometrial biopsy to determine hormonal effect on uterus and rule out malignancy Laparoscopy to evaluate for endometriosis

DUB- Management Treat underlying anemia with iron, possible transfusions Progesterone therapy to stop acute bleeding Oral contraceptives to control chronic bleeding Androgen therapy with danazol(Danocrine) to reduce menstrual blood loss by supressing the action of the anterior pituitary Dilation and curettage