MENSTRUAL IRREGULARITIES

dysmenorrhoea

DYSMENORRHOEA DEFENITION Painful menstruation Cases of painful menstruation of sufficient magnitude so as to incapacitate day to day activities

TYPES PRIMARY There is no identifiable pelvic pathology SECONDARY Pain occur due to a pelvic pathology

primary DYSMENORRHOEA

INCIDENCE OF PRIMARY DYSMENORRHOEA 5- 10%

CAUSES OF PRIMARY DYSMENORRHOEA DYSRYTHYMIC UTERINE CONTRACTION UTERINE HYPOXIA AND ISCHEMIA PAIN

CAUSES OF PRIMARY DYSMENORRHOEA Adolescents Related to ovulatory cycle Psychosomatic factors Tension and anxiety Lower pain threshold Abnormal anatomic and functional aspects of uterus Stenosis at the internal os In appropriate law of polarity Uterine myometrial hyperactivity Imbalance in the autonomic and nervous control Role of vasopressin Role of prostaglandin

CLINICAL FEATURE OF PRIMARY DYSMENORRHOEA Begins few hours before or just with the onset of menstruation Last for few hours may extend to 24 hrs but rarely 48hrs Spasmodic and confined to lower abdomen and may radiate to back and medial aspect of thigh Nausea Vomiting Fatigue Diarrhoea Head ache Vasomotor changes – pallor,cold,sweat and fainting

TREATMENT OF PRIMARY DYSMENORRHOEA Improve general health Psychotherapy Explanation and assurance Mild analgesic and anti spasmodic SEVERE CASES Prostaglandin synthetase inhibitors Mefanamic acid 250-500mg Flufenamic acid 100-200 mg ---- 8hrly Propionic acid derivative Ibuprofen 400mg ---- 8hrly Oral contraceptive pills

SURGICAL Rx OF PRIMARY DYSMENORRHOEA Dilatation of cervical canal Bilateral block of the pelvic plexus (Para cervical block with alcohol) Pre sacral neurectomy

SECONDARY DYSMENORRHOEA

DEFENITION Pain occur in the presence of a pelvic pathology

CAUSES OF SECONDARYDYSMENORRHOEA Premenstrual pelvic congestion or increased vascularity Increased tension in the pelvic tissue Pain

CAUSES OF SECONDARYDYSMENORRHOEA Chronic pelvic infection Pelvic endometriosis Adenomyosis Uterine fibroid Endometrial polyp IUCD in utero

CLINICAL FEATURES Pain is dull Situated in the back and front without any radiation Appears 3-5 days prior to the period Relieves with the start of bleeding

TREATMENT MEMBRANEOUS DYSMENORRHOEA Shedding of big endometrial casts Deficiency of tryptic ferment Rx ---same as primary dysmenorrhoea OVARIAN DYSMENORRHOEA Appears 2-3 days before menstruation Dull Distributed to one or both quadrant MITTELSCHMERZ’S SYNDROME Appears in the mid menstrual period Situated in the hypogastrium or to either iliac fossa Nausea and vomiting is absent Last more than 12hrs Vaginal bleeding or excessive vaginal discharge Rx --- Assurance and analgesics

Premenstrual syndrome

DEFINITION Premenstrual syndrome is a psycho neuro endocrine disorder of unknown etiology often noticed just prior to menstruation

CAUSES LINKED TO THE LEUTEAL PHASE Alteration in the level of estrogen and progesterone Decreased synthesis of serotonin Withdrawal of endorphins Psychological and psychosocial factors

CLINICAL FEATURES Abdominal bloating Breast tenderness Swelling of the extremities Weight gain Irritability Depression Insomnia Dyspareunia Anxiety Head ache Loss of concentration

TREATMENT GENERAL Assurance Avoidance of salt, caffeine and alcohol Pyridoxine 100mg,BD Diuretic – Frusemide 20mg Alprazolam 0.25mg (anxiety and depression) Fluoxetine HORMONES Oral contraceptive pills(Suppress ovulation) Progestogen 10mg (from 5th day of cycle for 20days) Bromocriptine 2.5mg(relieves breast discomfort) SUPPRESSION OF OVARIAN CYCLE Danazol 200-400mg (produce amenorrhoea) GnRH analouges (Gonadal steroids are suppressed)

Menorrhagia / HYPERMENORRHOEA

DEFINITION Menorrhagia is defined as cyclic bleeding at normal intervals Bleeding is either excessive in amount or duration or both

CAUSES ORGANIC Fibroid uterus Adenomyosis Pelvic endometriosis IUCD in utero Chronic tubo-ovarian mass Tubercular endometritis Retroverted uterus SYSTEMIC Liver dysfunction CCF Severe hypertension ENDOCRINAL Hypothyroidism Hyperthyroidism HEMATOLOGICAL DISORDERS ITP Leukemia Von willebrand’s disease FUNCTIONAL Hypothalamo – pituitary ,ovarian – endometrial axis

DIAGNOSIS Long duration of flow Passage of big clots Pallor Low Hb

TREATMENT Appropriate to the cause for menorrhagia

EPIMENORRHOEA/ POLYMENORRHOEA

DEFINITION It is defined as cyclic bleeding where the cycle is reduced to an arbitary limit of 21 days or less and remains constant at that frequency If the frequent cycle is associated with excessive and prolonged bleeding, it is called epimenorrhagia

CAUSES Hyper stimulation of the ovary by the pituitary hormone Adolescence Preceding menopause Following delivery and abortion PID(Ovarian hyperemia) Ovarian endometriosis (Ovarian hyperemia)

TREATMENT Hormonal Therapy

metrorrhagia

DEFINITION Metrorrhagia is defined as irregular acyclic bleeding from the uterus Bleeding from any part of the genital tract is included under metrorrhagia Contact bleeding or inter menstrual bleeding is also included

CAUSES CA cervix Polyp Infection Cervical endometriosis Ovular bleeding IUCD Decubitus ulcer

TREATMENT Malignancy should be excluded Treatment to the underlying pathology

MENOMETRORRHAGIA

DEFINITION When the bleeding is so irregular and excessive that the menses cannot be identified at all

CAUSES OF ACYCLIC BLEEDING CAUSES OF CONTACT BLEEDING CA Cervix Mucous polyp of cervix Ectopy of cervix Infection Cervical endometriosis CAUSES OF INTERMENSTRUAL BLEEDING Urethral caruncle Ovular bleeding IUCD in utero Decubitus ulcer

TREATMENT Malignancy should be excluded Treatment to the underlying pathology

oligomenorrhoea

DEFINITION Menstrual bleeding occuring more than 35 days apart and which remains constant at that frequency is called oligomenorrhoea

CAUSES Age Obesity Stress and exercise PCOD Hyperprolactenaemia Hyperthyroidism Androgen producing tumour Tubercular endometritis

hypomenorrhoea

DEFINITION When the menstrual period is unduly scanty and last for less than 2 days,it is called hypomenorrhoea CAUSES Uterine synachia Endometrial tuberculosis OCP Thyroid dysfunction Premenopausal period Malnutrition

amenorrhoea

DEFINITION Absence of menstruation

TYPES PRIMARY Delay of menarche past 17 years of age SECONDARY Menses ceases sometimes after menarche

CAUSES FOR PRIMARY AMENORRHOEA Anatomical defects in the structure of uterus and vagina Imperforate hymen Little or no development of secondary sex characteristics Genetic defects Intracranial lesions Pituitary failure

CAUSES FOR SECONDARY AMENORRHOEA Organic brain disease Ovarian neoplasm Polycystic ovary Nutritional Psychological disturbances Oral contraceptives

TREATMENT Treatment of underlying pathology

NURSING MANAGEMENT Medical evaluation Physical examination Vaginal smear Estrogen level TFT CBC Urinalysis Blood glucose level