Mrs. Mahdia Shaker RN, RM, APN. Menstrual disorders Mrs. Mahdia Shaker RN, RM, APN.

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

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: nutritional status Wt. & Ht. and vital signs Anorexia nervosa( hypothermia. Bradycardia, hypotension, and reduced subcutaneous fat) Androgen excess: facial hair and acne. Delayed puberty: absence of facial and axillary hair

Assessment: laboratory tests: U/S Pregnancy test Thyroid function test Prolactine level If high level of FSH: indicate ovarian failure If high level of LH: indicate gonadal dysfunction Laprascopy 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: Cyclic progesterone Promocriptine to treat hyperprolactinemia GnRH. When the cause is hypothalamic failure thyroid hormone replacement

Nursing 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, it’s 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: nausea vomiting diarrhea fatigue fever Headache or dizziness

Assessment: Focused history and physical examination: in primary dysmenorrhea: cramping pain with menstruation and the physical examination is completely normal 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: CBC to reveal anemia PT to detect blood disorders BHCG to rule out abortion or ectopic pregnancy 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: estrogen: cause vasospasm of the uterine arteries to decrease bleeding cyclic progesterone or long acting progesterone oral contraceptives: regulate the cycle and suppress the endometrium NSAIDs inhibit prostaglandin Iron replacement

Treatment: if the client doesn’t respond to medical therapy: D&C Endometrial ablation: is an alternative to hysterectomy Thermal balloon to ablate the endometrium

Nursing 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 Don’t simply encourage the woman to “live with it”.

Nursing management: It may result in the following complication: infertility from lack of ovulation anemia from prolonged bleeding 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: Depression Anxiety Irritability 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: Multivitamin daily Vitamin E,400units daily Calcium, 1,200mg daily Magnesium, 200-400mg daily

TREATMENT: NSAIDs taken a week prior to menses Drug therapy should be used cautiously: NSAIDs taken a week prior to menses Oral contraceptives ( low doses) Antidepressants Anxiolytics Diuretics