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

2. 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.

3. Etiology

4. 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.

5. 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.

6. Causes of secondary amenorrhea
Breast feeding
Emotional stress
Mal nutrition
Pregnancy
Pituitary, ovarian, or adrenal turners
Depression
Hyper thyroid or hypothermia

7. 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

8. 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

9. 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

10. 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

11. Therapeutic intervention for secondary amenorrhea:
Cyclic progesterone
Promocriptine to treat hyperprolactinemia
GnRH. When the cause is hypothalamic failure
thyroid hormone replacement

12. 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

13. 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

14. 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, mg or more daily)
weight-bearing exercise(30 minutes or more daily)
hormone replacement therapy

15. 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.

16. 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

17. 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

18. 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

19. 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

20. Treatement: pain relief : NSAIDs, cyclooxygenase- 2 inhibitor
hormonal contraceptives
life style changes:
daily ex.
limit salty foods
wt. loss
smoking cessation
rekaxation techniques

21. 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.

23. 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).

24. Etiology: adenomiosis pregnancy hormonal imbalance fibroid tumors
endometrial polyps or cancer
Endometriosis

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

26. 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

27. 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

28. 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

29. 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

30. 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”.

31. 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

32. 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.

33. 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.

34. 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.

36. 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.

37. 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

38. TREATMENT: Vitamins and mineral supplements: Multivitamin daily
Vitamin E,400units daily
Calcium, 1,200mg daily
Magnesium, mg daily

39. 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