1. MENSTRUAL DISORDERS
MELY K.

2. Specific Objectives
By the end of this session the Learner will be able to:
Define Normal menstruation
Classify Menstrual Disorders
Explain characteristics of the different menstrual disorders
Demonstrate ability to diagnose menstrual disorders
Apply Knowledge and skills acquired to manage menstrual disorders.

3. Definition of normal menstruation
It is the cyclical shading of a functional endometrium; and has the following characteristics:
Amount of flow: ml average 30 mls
Cycle length: days
Duration of flow: 2-7 days
Healthy menstrual blood does NOT coagulate
It occurs in a cyclic manner and regularly

4. Classification of menstrual disorders
Premenstrual syndrome (PMS)
Mastodynia
Abnormal bleeding due to gynecologic and non gynecologic disorders:
Amenorrhea, oligomenorhea, hypomenorrhea, menorrhagia, polymenorrhea, metrorrhagia, etc
Dysmenorrhoea
Dysfunctional uterine bleeding (DUB)
Post menopausal bleeding

5. Characteristics of Menstrual disorders

6. Premenstrual syndrome:
occurs in at least 3 consecutive menstrual cycles
Symptoms must occur in the 2nd half of the menstrual cycle (luteal phase)
There must be a symptom free period of at least 7 days in the 1st half of the cycle
Symptoms must be severe enough to require medical advise or treatment e.g. oedema, weight gain, restlessness, irritability and increased tension.

7. Premenstrual syndrome cont’d:
Symptoms include:
Mood symptoms ( irritability, mood swings, depression, anxiety)
Physical symptoms ( bloating, breast tenderness, insomnia, fatigue, hot flushes, appetite change, e.t.c)
Cognitive changes (confusion and poor concentration)

8. PMS -Diagnosis Mainly based on patient’s history
Patient charts symptoms for at least 3 symptomatic cycles
Rule out medical conditions that mimic PMS e.g. thyroid disease and anemia.

9. PMS- Management ( Conservative)
Diet: (limit caffeine, alcohol, tobacco and chocolate intake; eat small frequent meals
Decrease sodium intake
Stress management;
Aerobic exercises
Cognitive behavioral therapy

10. PMS management (Drug therapy)
Calcium carbonate (for bloating, pain and food cravings)
Magnesium ( for water retention)
Vitamin B6 and vitamin E
NSAIDs
Bromocryptine for mastalgia

11. Mastodynia Also termed mastalgia
Defined as: intolerable breast pain during the second half of the menstrual cycle.
caused by edema and engorgement of the vascular and ductal systems
Occurs cyclically in the luteal phase

12. Mastodynia -diagnosis
History and examination
Can be confirmed by aspiration
Ultrasound
Serial mammography
Excisional biopsy sometimes is necessary
Rule out: Mastitis, neoplasm

13. Mastodynia- treatment
Breast support
Avoid- coffee, tea, chocolate, cola drinks
Avoid nicotine
May occasionally use a mild diuretic
Drug therapy: topical NSAIDS, Gosarelin (Zoladex),
Limited success with: tamoxifen, danazol, bromocryptine, oral contraceptives, vitamins

14. Menorrhagia (Hypermenorrhea)
Defined as excessive, heavy or prolonged menstrual flow
Possible causes include: submucous myomas, adenomyosis, IUDs, endometrial hyperplasia, malignant tumors e.t.c

15. Hypomenorrhea (cryptomenorrhea)
Defined as unusually light menstrual flow sometimes only spotting
Possible causes include: hymenal or cervical stenosis, uterine synechiae (Asherman’s syndrome), occasionally oral contraceptives

16. Metrorrhagia (intermenstrual bleeding)
Defined as bleeding occurring any time between the menstrual periods
Possible causes include: endometrial polyps, CA cervix, CA endometrium, exogenous estrogen administration

17. Polymenorrhea Describes periods that occur too frequently
Usually associated with anovulation and rarely with a shortened luteal phase in the menstrual cycle

18. Menometrorhagia
This is bleeding that occurs at irregular intervals and varies in amount and duration of bleeding
Caused by any condition that can lead to intermenstrual bleeding

19. Oligomenorrhea
Describes menstrual periods that occur more than 35 days apart
Possible causes: anovulation which may be from endocrine causes (pregnancy, menopause, pituitary and hypothalamic disorders); or systemic causes (excessive weight loss); estrogen secreting tumors etc

20. AMENORRHEA No menstrual period for more than 6 months Possible causes:
Congenital uterine absence
Hormonal disturbances from the hypothalamus and pituitary gland
Failure of the ovary to receive or maintain egg cells
Genetic diseases e.g. causes of intersex i.e. 5-alpha-reductase deficiency

21. Diagnosis in abnormal uterine bleeding
History and physical examination
Cytological examination –include biopsy and histology
Pelvic ultrasound scan
Endometrial biopsy
Hysteroscopy
Dilatation and curettage
Hormonal profile
Blood tests- Haemogram, thyroid function tests e.t.c.

22. Management of abnormal uterine bleeding- principles
Treat cause appropriately
May include
Hormonal preparations
Surgery
Endometrial ablation and endometrial resection, Prostaglandin synthetase inhibitors,
Levonogestrel releasing IUDs

23. Dysmenorrhea Definition: Pain associated with menstruation
Risk factors:
Menstrual factors (early menarche, menorrhagia)
Parity (lower in multipara)
Diet (reduced intake of fish, eggs and fruits)
Exercise (reduces dysmenorrhoea)
Cigarette smoking (increases)
Psychological (emotionally dependent and overprotected girls, family history,)

24. Dysmenorrhea- classification
Primary or spasmodic dysmenorrhea:
Essential/ intrinsic / functional. Defined as painful menstruation in absence of pelvic pathology
Usually starts at puberty
Follows onset of ovulation and presents throughout period of bleeding.
Congestive or secondary dysmenorrhea:
Underlying pelvic disease e.g. uterine abnormalities, infections, endometriosis, foreign bodies, iatrogenic
Membranous dysmenorrhea:
associated with passage of endometrial cast through an undilated cervix.

25. Dysmenorhea- clinical features
Primary Dysmenorhea:
Age: Usually seen among younger women
Time of onset: 2-3 yrs after menarche
Duration of pain: starts just prior to menses, lasts about 2 days
Type of pain: cramping pain
Membranous Dysmenorhea:
Intense cramping pain associated with passage of an endometrial cast through an undilated cervix.

26. Dysmenorhea- clinical features (ctd)
Secondary Dysmenorhea:
- Associated with specific diseases and disorders e.g. PID, Uterine fibroids, endometriosis etc
Usually among older women (3rd to 4th decade)
Time of onset: follows initial years of normal painless cycles
Duration of pain: Onset is few days prior to menses and continues throughout cycle even after cessation of menses
Type of pain: continuous dull aching or dragging pain

27. Dysmenorhea -management
Assurance
Laxatives
Analgesics and Antispasmodics
Fails
Contraception not required or OC pills contraindicated
Contraception required or NSAIDS contra indicated
Prostaglandin synthetase inhibitors
OC pills
Fails
Laparoscopy to look for causes of secondary Dysmenorhea
No cause found but persistent and severe pain
Cause found
Treat as appropriate
Surgery

28. Dysfunctional Uterine bleeding (DUB)
Defined as a symptom complex that includes any condition of abnormal uterine bleeding in the absence of pathologic cause
Commonly caused by anovulation as seen in polycystic ovarian disease and obesity
May occur in all age groups from prepubertal girls to menopausal women

29. DUB management Medical management: Surgical NSAIDS
Antifibrinolytic agents
Hormones
Surgical
Endometrial resection
Endometrial ablation
hysterectomy

30. Postmenopausal bleeding
Any vaginal bleeding in a postmenopausal women should be considered abnormal
Frequently associated with malignancies of the reproductive tract
Benign causes include: endometrial /cervical polyps, trauma, senile vaginitis, vulval dystrophies
Management depends on the cause.

31. Thank You