DYSMENORRHEA
at the time of OVULATION (“MITTELSTAINING”)
 is a PAINFUL MENSTRUATION
 caused by the RELEASE of PROSTAGLANDINS in
response to TISSUE DESTRCUTION during the
ISCHEMIC PHASE of menstrual cycle.
 Can also be a PRELLIMINARY SYMPTOM of an
UNDERLYING ILLNESS such as PID, UTERINE
MYOMAS (tumors) or ENDOMETRIOSIS.
CATEGORY:
1. MILD – NO INTERFERENCE with NORMAL
activities.
2. MODERATE – SOME INTERFERENCE
3. SEVERE – INTERFERENCE with the MAJORITY of
EVERYDAY activities.
 PRIMARY – if it occurs in the ABSENCE of
ORGANIC DISEASE.
 SECONDARY – if it occurs as a RESULT of
ORGANIC DISEASE.
SYMPTOMS:
1. Begins with “BLOATED” FEELING and LIGHT
CRAMPING 24 HOURS before menstrual flow.
2. PAIN
3. COLICKY (sharp) PAIN is superimposed on a
DULL, NAGGING pain across the LOWER
ABDOMEN.
4. “ACHING, PULLING” sensation of the VULVA and
INNER THIGHS.
5. Some have MILD DIARRHEA with ABDOMINAL
CRAMPING.
6. MILD BREAST TENDERNESS, ABDOMINAL
DISTENTION, NAUSEA, VOMITING HEADACHE
and FACIAL FLUSHING.
MGMT:
 ANALGESIC such as ACETYLSALICYLIC ACID
(APIRIN)
 IBUPROFEN (ADVIL, MOTRIN)
 NAPROXEN SODIUM (ALEVE) is also effective.
 LOW-DOSE ORAL CONTRACEPTIVES to PREVENT
OVULATION may also be effective if pregnancy is
NOT DESIRED.
 IMAGERY
 TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION (TENS)
MENORRHAGIA
 An ABNORMALLY HEAVY MENSTRUAL FLOW
 Defined as GREATER THAN 80ML PER MENSES
 May occur in girls CLOSE TO PUBERTY and it
occurs again in women NEARING MENOPAUSE
because of ANOVULATORY CYCLES.
 Can indicate ECDOMETRIOSIS, ANEMIA, BLOOD
DYSCRASIA such as clotting defect, or a uterine
abnormality such as myoma (fibroid) tumor, PID,
or early pregnancy loss, VON WILLEBRAND
DISEASE.
ASSESSMENT & THERAPY
1. PAD/TAMPON SATURATED in less than 1 HOUR.
2. If ANEMIA occurs – IRON SUPPLEMENTS
3. PROGESTERONE during LUTEAL PHASE – for
EXCESSIVE BLOOD LOSS due to ANOVULATORY
CYCLES.
4. LOW-DOSE ORAL CONTRACEPTIVE
METRORRHAGIA
 BLEEDING BETWEEN MENSTRUAL PERIODS.
 NORMAL in ADOLESCENTS who have SPOTTING
 Also occur in TEENAGERS TAKING ORAL
CONTRACEPTIVES (breakthrough bleeding)
during the FIRST 3-4 MONTHS OF USE.
 VAGINAL IRRITATION from infection can cause
MIDCYCLE SPOTTING.
MENSTRUAL MIGRAINE
 MENSTRUAL MIGRAINE HEADACHE – refers to a
SHARP, DISABLING HEADACHE, often
accompanied by NAUSEA/VOMITING or VISION
at the same time.
 Occurs as the SAME TIME AS MENSTRUAL
FLOW.
ENDOMETRIOSIS
 Is an ABNORMAL GROWTH OF EXTRAUTERINE
ENDOMETRIAL CELLS often in the CUL-DE-SAC of
the peritoneal cavity or on the UTERINE
LIGAMENTS or OVARIES.
 Results from EXCESSIVE ENDOMETRIAL
PRODUCTION and a REFLUX of blood and tissue
through the fallopian tubes during a menstrual
flow.
 50% of adolescents seen for dysmenorrhea have
ENDOMETRIOSIS.
ASSESSMENT:
1. PELVIC EXAMINATION show uterus is displaced
by TENDER, FIXED, PALPABLE NODULES.
2. Nodules in the CUL-DE-SAC or on an OVARY also
may be PALPABLE.
3. If MINIMAL – NO SYMPTOMS
4. If MODERATE/EXTENSIVE – EXTREME
DYSMENORRHEA/DYSPAREUNIA
AMENORRHEA
 ABSENCE OF MENSTRUAL FLOW
 SIGN OF PREGNANCY
 Associated with LOW RATIO OF BODY FAT TO
BODY MUSCLE, which leads to EXCESSIVE
SECRETION of PROLACTIN.
 An ELEVATION IN PROLACTIN causes a
DECREASE in GnRH from the hypothalamus,
followed by DECLINES in FSH, follicular
development and estrogen secretion.
PRE-MENSTRUAL DYSMORPHIC DISORDER (PDD)
 A condition that occurs in the LUTEAL CYCLE and
is relieved by ONSET OF MENSES.
 Associated with SEVERE EMOTIONAL and
PHYSICAL PROBLEMS (has both BEHAVIORAL &
PHYSIOLOGIC SYMPTOMS)
 Woman has SEVERE DEPRESSION, SYMPTOMS,
IRRITABILITY and TENSION before menstruation.
CAUSES, INCIDENCE and RISK FACTORS…
 POOR RENAL CLEARANCE leading to WATER
RETENTION
 HYPOGLYCEMIA leading to a SURGE of
EPINEPHRINE and LOW CALCIUM LEVELS and
INTERFERENCE with SEROTONIN SYNTHESIS.
PDD or PMDD
 many women with this condition have:
 anxiety
 major depression
 seasonal affective disorder (SAD)
  other factors that may play a role include:
 ALCOHOL ABUSE
 being OVERWEIGHT
 drinking LARGE AMOUNTS of CAFFEINE
 having a MOTHER with a HISTORY OF THE
DISORDER
 LACK OF EXERCISE
FIVE or MORE OF THE FF SYMPTOMSMUST BE PRESENT
TO DIAGNOSE PMDD, including ONE MOOD related
symptom:
 DISINTEREST in daily activities and relationships
 FATIGUE/LOW ENERGY
 FEELING OF SADNESS/HOPELESSNESS, possible
SUICIDAL THOUGHTS (depression)
 FEELINGS OF TENSION/ANXIETY
 FEELING OUT OF CONTROL
 FOOD CRAVINGS or BINGE EATING (appetite
disturbance)
 MOOD SWINGS marked by periods of
TEARINESS
 PANIC ATTACK
 PERSISTENT IRRITABILITY or ANGER that affects
other people.
 PHYSICAL SYMPTOMS, such as BLOATING,
BREAST TENDERNESS, HEADACHES,
JOINTS/MUSCLE PAINS.
 PROBLEMS IN SLEEPING
 TROUBLE CONCENTRATING
DIAGNOSIS:
 NO PHYSICAL EXAMINATION/LAB TESTS CAN
DIAGNOSE PMDD.
 A complete history, physical examination
(including a pelvic exam), psychiatric evaluation
should be done to rule out other conditions.
 Keeping a calendar/diary of symptoms can help
women identify the most TROUBLESOME
symptoms and the times when they are likely to
occur.
TREATMENT:
 ANTIDEPRESSANT (BUSPIRONE)(BuSpar) – if
WITH DEPRESSION.
FEMALE CIRCUMCISION
 INCISION and REMOVAL of the CLITORIS.
 NO MEDICAL REASON or ADVANTAGE; regarded
as coming of AGE RITUAL in some cultures.
 May have DIFFICULTY WITH CHILDBIRTH
because VULVAR SCARRING and CONTRACTION.
IMPERFORATE HYMEN
 Totally OCCLUDES VAGINA, PREVENTING the
ESCAPE OF VAGINAL SECRETIONS and
MENSTRUAL BLOOD.
 NO SYMPTOMS BEFORE MENARCHE.
 With ONSET of menstruation, MENSTRUAL
FLOW IS OBSTRUCTED and BUILDS UP VAGINA,
causing:
 INCREASED PRESUURE in the VAGINA
and UTERUS.
 ABDOMINAL PAIN
 LOWER ABDOMINAL MASS ON PALPATION
 INTACT, BULGING HYMEN is evident on vaginal
exam.
POLYCYSTIC OVARY SYNDROME (PCOS)
 Most frequent cause of OVULATION FAILURE.
 Cause is unknown.
 Most adolescent WITH PCOS is OBESE.
 A PERPLEXING DISORDER because of its WIDE
RANGE OF SYMPTOMS and NON-IMMEDIATE
RESPONSE TO THERAPY.
S/S:
 IRREGULAR/MISSED PERIODS
 ACNE
 EXCESSIVE HAIR GROWTH (HIRSUTISM)
 OVERWEIGHT
 MALE PATTERN BALDNESS
 TYPE 2 DIABETES
 ABSENCE OF OVULATION

 HEALTHY LIFESTYLE – 1ST ASSESSMENT/DX:

 Eat a BALANCED DIET (HIGH in vits & CALCIUM
& LOW in salt)  HX
 Get REGULAR AEROBIC EXERCISE throughout  Physical Exam
the month.  Pelvic Exam
 TRY CHANGING YOUR SLEEP HABITS before  Ovarian Ultrasound
taking drugs for insomnia.  Serum Androgen
 Keep a diary/calendar to record:  Glucose level determination
 The TYPE OF SYMPTOMS you are
MGMT/TREATMENT:
having
 How SEVERE they are  Weight LOSS
 How LONG THEY LAST  LOWER GLUCOSE LEVEL
 ANTIDEPRESANTS may be helpful.  IMPROVE body’s USE OF INSULIN
 Normalize testosterone secretion
OTHER TREATMENTS:
 Bariatric surgery – if MORBIDITY OBESE
 BIRTH CONTROL PILLS may  COC
DECREASE/INCREASE PMS SYMPTOMS,  METFORMIN (GLUCOPHAGE)
including DEPRESSION or the GnRH AGONIST  CLOMIPHENE (CLOMID)
LEUPROLIDE.  IVF and Ovarian Drilling
 DIURETICS may be useful for women who GAIN  ANTIANDROGENS
A LOT OF WEIGHT from FLUID RETENTION.
 Nutritional Supplements TOXIC SHOCK SYNDROME
 Other medicines (such as DEPO-LUPRON)
 An INFECTION usually caused by TOXIN-
SUPPRESS THE OVARIES and OVULATION.
PRODUCING STRAINS of STAPHYLOCOCCUS
 PAIN RELIEVERS such as ASPIRIN or IBUPROFEN
AUREUS ORGANISMS.
may be prescribed for HEADACHE, BACKACHE,
 ORGANISMS ENTER THRU VAGINAL WALLS that
MENSTRUAL CRAMPING, BREAST TENDERNESS.
have been DAMAGED by the INSERTION of
TAMPONS at the time of a MESNTRUAL PERIOD.
ASSESSMENT:

 MILD DIARRHEA as a NORMAL accompaniment

to DYSMENORRHEA.
 FEVER WITH DIARRHEA and VOMITING DURING
A MENSTRUAL PERIOD (is suspected TSS)

MGMT:

 CAREFUL VAGINAL EXAM and REMOVAL of ANY

TAMPON PARTICLES.
 CERVICAL and VAGINAL CULTURES for S. Aureus
 IODINE DOUCHES – to REDUCE NUMBER OF
ORGANISMS present vaginally.
 PENICILLINASE - RESISTANT ANTIBIOTICS:
CEPHALOSPORINS, OXACILLINS,
CLINDAMYCINS.
 IVF therapy - to RESTORE CIRCULATING FLUID
VOLUME and INCREASE BP or VASOPRESSORS
such as DOPAMINE (INTROPIN) to INCREASE BP.
 OSMOTIC THERAPY - to SHIFT FLUID BACK into
INTAVASCULAR CIRCULATION – to PREVENT
RENAL AND CARDIAC FAILURE.
 Recovery occurs in 7-10 DAYS; FATIGUE and
WEAKNESS may remain for MONTHS
AFTERWARD.

VULVOVAGINITS

 INFLAMMATION of the VULVA/VAGINA is

accompanied by PAIN, ODOR PRURITIS and a
VAGINAL DISCHARGE.
 VAGINAL BLEEDING may be present.
 May occur at ANY AGE but more frequent at
PUBERTY.
 Change to adult Ph and PRESENCE OF VAGINA
SECRETIONS MAKE VAGINA MORE RECEPTIVE
TO INFECTIONS.

PRESCHOOL & SCHOOL-AGE CHILDREN:

 BLEEDING IS RARELY SEEN AT THIS AGE.

 If bleeding is present, its cause must be
determined.
 CYSTITIS can cause URETHRAL BLEEDING;
SCRATCHING due to RECTAL PRURITUS can lead
to RECTAL BLEEDING.
 If cause is FOREUGN BODY, REMOVE IT.
 LOCAL ANTIBIOTIC OINTMENT or WARM BATH
– to reduce accompanying INFECTION and
INFLAMMATION afterward.

PELVIC INFLAMMATORY DISEASE

 INFECTION of the PELVIC ORGANS: UTERUS,

FALLOPIAN TUBES, OVARIES and their
SUPPORTING STRUCTURES.
 Infection can EXTEND TO CAUSE PELVIC
PERITONITIS.
 Frequent cause: GONORRHEAL and
CHLAMYDIAL ORGANISM.
 Other causes: E. Coli or STREPTOCOCCUS (may
be severe)
 Begins with CERIVICAL INFECTION that SPREADS
BY SURFACE INVASION along the UTERINE
ENDOMETRIUM and then OUT to the
FALLOPIAN TUBES and OVARIES.
