MENSTRUATION DISORDERS

• AMENORRHEA:
• DEFINITION
• Normally, woman goes through regular monthly cycle called menstruation. some
problems can impede the cycle Amenorrhea: is the absence of menstruation.
May be primary or secondary
• Primary amenorrhea is the absence of menstrual bleeding and secondary sexual
characteristics in a girl by age 14 years or the absence of menstrual bleeding with
normal development of secondary sexual characteristics in a girl by age 16 years.
• Secondary amenorrhea is the absence of menstrual bleeding in a woman who
had been menstruating but later stops menstruating for three or more months (3
cycles or more).
• Functional causes
• Anorexia/bulimia –
• Chronic diseases (for example, tuberculosis)
• Excessive weight gain or weight loss
• Depression , Psychotropic drug use (drugs prescribed to stabilize or
improve mood, mental status, or behavior)
• Excessive stress, Excessive exercise
• Cycle suppression with systemic hormonal contraceptive pills
• Structural causes:
• Hypergonadotropic hypogonadism
• Premature ovarian failure
• Hypogonadotropic hypogonadism
• Hypothalamic hypogonadism
• Pituitary disease
• Thyroid disease
• Absence of the uterus, cervix, or vagina
• Pregnancy Hyperprolactinemia
• Elevated levels of androgens (male hormones)
• Polycystic ovary syndrome PCOS
AMENORRHEA: SIGNS AND
SYMPTOMS
• Milky nipple discharge.
• Unwanted hair growth.
• Headache.
• Vision changes.
• Excess facial hair.
• Pelvic pain.
• Acne
• stops having menstrual periods for three cycles in a row.
TREATMENT

• Non-pharmacological treatment:
• women should eat a properly balanced diet.
• women should restrict the amount of fat in their diet
• A moderate exercise program may restore normal menstruation. -
restore and maintain a healthy body weight.
• finding ways to deal with stress and conflicts may help.
• Maintaining a healthy lifestyle by avoiding alcohol consumption and
cigarette smoking is also helpful.
Management
• For primary amenorrhea, depending on age and the results of the
ovary function test, health care providers may recommend watchful
waiting. If an ovary function test shows low follicle-stimulating
hormone (FSH) or luteinizing hormone (LH) levels, menstruation may
just be delayed. In females with a family history of delayed
menstruation, this kind of delay is common.
• Treatment for secondary amenorrhea, depending on the cause, may
include:
Pharmacological treatment:

• Drugs used in polycystic ovary syndrome to induce ovulation:

Metformin and Clomiphene citrate
• Dopamine receptor agonists; for treating hyperprolactinemia:
Bromocriptine , Cabergoline
• Hormone replacement therapy HRT consisting of an estrogen and/or
a progestrone can be used in estrogen deficiency: Dydrogesterone
(Duphaston, Abbott) Progesterone micronized.
• Medroxyprogestrone acetate (Provera, Pfizer)
• Norethistterone acetate (Primolut-Nor, BAYER)
• In some cases, oral contraceptives may be prescribed to restore the
menstrual cycle. Before administering oral contraceptives, withdrawal
bleeding is induced with an injection of progesterone or oral
administration of 5-10 mg of medroxyprogesterone for 10 day
SIDE EFFECTS:
• Dizziness, spinning sensation, mild drowsiness mild headache,
depressed mood, sleep problems (insomnia)
• Upset stomach, nausea, vomiting, stomach pain, loss of appetite,
diarrhea, constipation acne, hair growth or hair loss .
• Changes in menstrual periods, vaginal itching or discharge • changes
in appetite, increased or decreased weight
2. DYSMENORRHEA
• PREMENSTURAL SYNDROME Premenstrual symptoms occur between
ovulation and the start of menstrual bleeding(one to two weeks before a
woman's period)
• Common physical symptoms - Bloating , weight gain - Fatigue , lack of
energy - Cramps ,aching muscles and joints, low back Pain - Sleeping too
much or too little , Constipation and diarrhea , Acne
• Mood and behavior symptoms - Sad or depressed mood - Anger,
irritability, aggression
• Anxiety - Mood swings - Decreased alertness, trouble concentrating -
Withdrawal from family and friends
PREMENSTRUAL DYSPHORIC DISORDER (PMDD)

• - PMDD is characterized by depressed or labile mood, anxiety,

irritability, anger, and other symptoms occurring exclusively during
the 2 weeks preceding menses.
• Other symptoms may include the following: • Decreased interest in
usual activities (eg, work, school, friends, and hobbies)
• Other physical symptoms, such as breast tenderness or swelling,
headaches, joint or muscle pain, a sensation of bloating, or weight
gain
• It have more severe symptoms when compered with PMS
DYSMENORRHEA
• DEFINITION Dysmenorrhea :painful cramps that may occur immediately
before or during the menstrual period.
• There are two types of dysmenorrhea: primary and secondary dysmenorrhea:
• Primary dysmenorrhea is cramping pain in the lower abdomen occurring just
before or during menstruation, in the absence of other diseases such as
endometriosis. •
• Secondary dysmenorrhea is pain caused by a disorder in the woman's
reproductive organs, such as endometriosis, adenomyosis, uterine fibroids, or
infection.
• Pain from secondary dysmenorrhea usually begins earlier in the menstrual
cycle and lasts longer than common menstrual cramps.
ETIOLOGY

• Risk factors for primary dysmenorrhea include the following:

• Early age at menarche (< 12 years)
• Nulliparity
• Heavy or prolonged menstrual flow
• Smoking
• Positive family history
• Obesity
• Risk factors for secondary dysmenorrhea include the following : -
• Leiomyomata (fibroids)
• Pelvic inflammatory disease
• Tubo-ovarian abscess
• Ovarian torsion
• Endometriosis
DYSMENORRHEA: SIGNS &
SYMPTOMS
• Primary dysmenorrhea
• Onset shortly after the first occurrence of menstruation (≤6 months)
• Usual duration of 48-72 hours (often starting several hours before or
just after the menstrual flow)
• Cramping or laborlike pain
• lower abdominal pain, radiating to the back or thigh .
• Secondary dysmenorrhea
• Dysmenorrhea beginning in the 20s or 30s, after previous relatively
painless cycles .
• Heavy menstrual flow or irregular bleeding
• Dysmenorrhea occurring during the first or second cycles after
menarche (menarch is the first occurrence of menstruation)
• Pelvic abnormality with physical examination
• Poor response to nonsteroidal antiinflammatory drugs (NSAIDs) or oral
contraceptives (OCs)
• Infertility • Dyspareunia • Vaginal discharge
PHARMACOLOGICAL TREATMENT.
• NSAIDs are common treatment for both primary and secondary dysmenorrhea
• NSAIDs are highly effective in treating dysmenorrhea, especially when they are
started before the onset of menses and continued through day 2.
• They decrease menstrual pain by decreasing intrauterine pressure and lowering
prostaglandin F2α .
• The most common side effect of NSAIDs is the GI upset.
• NSAIDs approved by the FDA for treatment of dysmenorrhea are as follows:
• Diclofenac Immediate-release (Cataflam): 100 mg PO once, then 50 mg PO q8hr
PRN
• Ibuprofen OTC: 200-400 mg PO q4-6hr; not to exceed 1.2 g unless directed by
physician.
• Ketoprofen Immediate-release: 25-50 mg q6-8hr PRN.
• Mefenamic acid for Primary Dysmenorrhea ,Initial 500 mg PO once,
Then250 mg PO q6hr PRN usually not to exceed 3 days
• Naproxen :500 mg PO initially, then 250 mg PO q6-8hr or 500 mg PO
q12hr (long-acting formula); not to exceed 1250 mg/day on first day;
subsequent doses should not exceed 1000 mg/day.
• Other NSAIDs and analgesics that have been used include the following:
Aspirin may not be as effective as these NSAIDs, and acetaminophen
may be a useful adjunct for alleviating only mild menstrual cramping
pain, and both aspirin and acetaminophen are used when other NASID
are not tolerated .
• COX-2 inhibitors have also been used in relieving menstrual pain. They selectively
inhibit COX-2 receptor and reduse GI symptoms. But NASID remain better .
• Montelukast : they reduce menstrual pain. They are considered as alternative to
hormonal therapy and NSAIDs.
• Oral contraceptives (Ocs) may be an appropriate choice for patients who are not
planning to be pregnant .
• Combination OCs suppress the hypothalamic-pituitary-ovarian axis, thereby inhibiting
ovulation and preventing prostaglandin production. Although not approved by the
FDA for treating dysmenorrhea, the following Ocs are also used:
• -Combination OCs (eg, ethinyl estradiol with progestin or drospirenone) .
• -Levonorgestrel intrauterine device .
• -Depot medroxyprogesterone acetate
• Analgesics In an emergency setting, patients who do not respond to
NSAIDs may require treatment with narcotics for pain control.
Moderate to Severe Pain 1-2 tablets (2.5-10 mg hydrocodone; 300-
325 mg acetaminophen) PO q4-6hr PRN
• Acetaminophen: Not to exceed 1 g/dose or 4 g/24 hr
• Hydrocodone: Maximum daily dose should not exceed 60 mg/24 hr
NONPHARMACOLOGICAL
TREATMENT

• Exercise
• Heat. Using a hot bath or a heating pad, hot water bottle or heat patch
on your lower abdomen may ease menstrual cramps.
• Dietary supplements. A number of studies have indicated that vitamin
E, omega-3 fatty acids, vitamin B-1 (thiamine), vitamin B-6 and
magnesium supplements may effectively reduce menstrual cramps.
• Avoiding alcohol and tobacco. These substances can make menstrual
cramps worse. 5. Reducing stress. Psychological stress may increase
your risk of menstrual cramps and their severity
• primary dysmenorrhea is treated by relief cramping pelvic pain and
associated symptoms that accompany menstrual flow. (NSAIDs) and
(OCs) are the most commonly used as treatment for the management
of primary dysmenorrhea.
• secondary cause(treat pelvic pathology like endometriosis) . use of
analgesic agents and narcotics as adjunctive therapy may be
beneficial. dysmenorrhea is treated by correction of the underlying
organic
MENORRHAGIA
• DEFINITION
• is a menstrual period with abnormally heavy flow and falls under the larger
category of abnormal uterine bleeding (AUB)
• SIGNS & SYMPTOMES
• saturation of one or more sanitary pads or tampons every hour for several
hours .
• use of double sanitary protection - Menstrual flow or bleeding lasting more
than 1 week
• Passage of blood clots which are the size of a quarter or larger
• Signs and symptoms of anemia which include tiredness, fatigue and shortness
of breath Constant lower abdominal and pelvic pain.
MENORRHAGIA: ETIOLOGY

•Hormonal disturbances
•Ovarian dysfunction
• Uterine fibroids
• Intrauterine Device (IUD)
•Pregnancy-related complications such as a miscarriage cervical or ovarian cancers
Inherited bleeding disorders such
•Platelet function disorder Medications, such as anti-inflammatory and
anticoagulants
•thyroid disorders,
•endometriosis,
•and liver or kidney disease.
MENORRHAGIA: PHARMACOLOGICAL THERAPY

• iron supplementation to treat anemia •

• NSAIDs: Ibuprofen, Naproxen...
• Oral contraceptives • Oral progesterone: levonorgestrel (Microlut,
BAYER) Medroxyprogestrone acetate (Provera, Pfizer) (Oralut, BZ)
• Anti-fibrinolytic drug: tranexamic acid (Hexakapron, TEVA), used in the
treatment of hemorrhages.
NON PHARMACOLOGICAL THERAPY

• Ginger
• Cinnamon
• Mustard seeds
• Omega -3
• Diet: Diet should be rich in vitamins and minerals like magnesium ,
iron and calcium .The diet should contain lots of fresh fruits and
vegetables, green vegetables.
• ASANTENI