Menstrual disordersMenstrual disorders

Amenorrhea Amenorrhea Absence of menses during the reproductive year's Absence of menses during the reproductive year's

categories of amenorrhea:- categories of amenorrhea:- categories of amenorrhea:-categories of amenorrhea:-A: Primary amenorrheaA: Primary amenorrhea: is defined as:-: is defined as:-- Absence of menses by age 14 with absence of - Absence of menses by age 14 with absence of

growth and development of secondary sexual growth and development of secondary sexual chch.chch.

- Absence of menses by age 16 with normal - Absence of menses by age 16 with normal development of secondary sexual chch.development of secondary sexual chch.

B: secondary amenorrheaB: secondary amenorrhea: : is the absence of is the absence of menses for 3 cycles or 6 months in women who menses for 3 cycles or 6 months in women who have previously menstruated regularly.have previously menstruated regularly.

EtiologyEtiology

EtiologyEtiology Causes of primary amenorrhea:Causes of primary amenorrhea:1- Extreme wt gain or loss.1- Extreme wt gain or loss.2- Congenial abnormalities of the 2- Congenial abnormalities of the

reproductive system.reproductive system.3- Stress from a major life event.3- Stress from a major life event.4- Excessive exercises4- Excessive exercises5- Eating disorders (anorexia nervosa)5- Eating disorders (anorexia nervosa)6- Polycystic ovarian syndrome.6- Polycystic ovarian syndrome.7- Hypothyroidism.7- Hypothyroidism.

Causes of primary Causes of primary amenorrhea:amenorrhea:

8- Turner syndrome.8- Turner syndrome.9- Imperforated hymen.9- Imperforated hymen.10- Chronic illness10- Chronic illness11- Pregnancy.11- Pregnancy.12- Cystic fibrosis.12- Cystic fibrosis.13- Congenial heart disease.13- Congenial heart disease.14- Ovarian or adrenal tumors.14- Ovarian or adrenal tumors.

Causes of secondary Causes of secondary amenorrheaamenorrhea

Breast feedingBreast feeding Emotional stressEmotional stress Mal nutritionMal nutrition PregnancyPregnancy Pituitary, ovarian, or adrenal turnersPituitary, ovarian, or adrenal turners DepressionDepression Hyper thyroid or hypothermiaHyper thyroid or hypothermia Mal nutritionMal nutrition

Causes of secondary Causes of secondary amenorrheaamenorrhea

Hyper prolactinemiaHyper prolactinemia Rapid wt gain or lossRapid wt gain or loss Chemotherapy or radiotherapyChemotherapy or radiotherapy Vigorous excreteVigorous excrete Kidney failureKidney failure ColitisColitis Tranquilizers or antidepressant Tranquilizers or antidepressant Post partum pituitary necrosis Post partum pituitary necrosis Early menopause Early menopause

Assessment:Assessment: history of etiologic factorshistory of etiologic factors physical examination for:physical examination for:1.1. nutritional statusnutritional status2.2. Wt. & Ht. and vital signs Wt. & Ht. and vital signs 3.3. Anorexia nervosa( hypothermia. Bradycardia, Anorexia nervosa( hypothermia. Bradycardia,

hypotension, and reduced subcutaneous fat)hypotension, and reduced subcutaneous fat)4.4. Androgen excess: facial hair and acne.Androgen excess: facial hair and acne.5.5. Delayed puberty: absence of facial and Delayed puberty: absence of facial and

axillary hairaxillary hair

Assessment:Assessment: laboratory tests:laboratory tests:1.1. U/S U/S 2.2. Pregnancy testPregnancy test3.3. Thyroid function testThyroid function test4.4. Prolactine levelProlactine level5.5. If high level of FSH: indicate ovarian If high level of FSH: indicate ovarian

failurefailure6.6. If high level of LH: indicate gonadal If high level of LH: indicate gonadal

dysfunctiondysfunction7.7. LaprascopyLaprascopy8.8. CTCT

Treatment:Treatment: depend on the depend on the cause: cause:

In primary amenorrhea:In primary amenorrhea: correct the underlying causecorrect the underlying cause estrogen replacement therapy estrogen replacement therapy if pituitary tumor: treatement with if pituitary tumor: treatement with

surgical resection, radiation and drug surgical resection, radiation and drug therapytherapy

surgery to correct abnormalities of surgery to correct abnormalities of genital tractgenital tract

Therapeutic intervention Therapeutic intervention for secondary amenorrhea:for secondary amenorrhea:Therapeutic intervention for Therapeutic intervention for

secondary amenorrhea:secondary amenorrhea: Cyclic progesteroneCyclic progesterone Promocriptine to treat Promocriptine to treat

hyperprolactinemiahyperprolactinemia GnRH. When the cause is GnRH. When the cause is

hypothalamic failure hypothalamic failure thyroid hormone replacementthyroid hormone replacement

Intervention:Intervention: counseling and educationcounseling and education adres the diverse causes of amenorrhea, the adres the diverse causes of amenorrhea, the

relationship to sexual identity, possible relationship to sexual identity, possible infertilityinfertility

inform the woman about the purpose of each inform the woman about the purpose of each diagnostic testdiagnostic test

sensitive listening, interviewing, and sensitive listening, interviewing, and presenting treatement optionspresenting treatement options

Nutritional counseling Nutritional counseling Emphasize healthy life styleEmphasize healthy life style

Teaching guidelines for Teaching guidelines for maintaining healthy life style:maintaining healthy life style:

balance energy expenditure with energy balance energy expenditure with energy intakeintake

modify diet to maintain ideal Wtmodify diet to maintain ideal Wt avoid excessive use of alcohol and mood-avoid excessive use of alcohol and mood-

altering or sedative drugsaltering or sedative drugs Avid cigarette smokingAvid cigarette smoking Identify areas emotional stress and seek Identify areas emotional stress and seek

assistance to resolve themassistance to resolve them Balance work, recreation, and restBalance work, recreation, and rest

Teaching guidelines for Teaching guidelines for maintaining healthy life style:maintaining healthy life style:

Maintain a positive outlook regarding the Maintain a positive outlook regarding the diagnosis and prognosisdiagnosis and prognosis

Participate in ongoing care to monitor Participate in ongoing care to monitor replacement therapy or associated replacement therapy or associated conditions.conditions.

Maintain bone density through:Maintain bone density through:– calcium intake( 1,200-1.5 mg or more daily)calcium intake( 1,200-1.5 mg or more daily)– weight-bearing exercise(30 minutes or more weight-bearing exercise(30 minutes or more

daily)daily)– hormone replacement therapyhormone replacement therapy

DysmenorrheaDysmenorrhea Etiology:Etiology: Primary dysmenorrhea: caused by increased Primary dysmenorrhea: caused by increased

prostaglandin production by the endometrium prostaglandin production by the endometrium in an ovulatory cycle which cause contraction in an ovulatory cycle which cause contraction of the uterus. The highest level is in the first 2 of the uterus. The highest level is in the first 2 days of menses.days of menses.

Secondary dysmenorrhea: is painful Secondary dysmenorrhea: is painful menstruation due to pelvic or uterine menstruation due to pelvic or uterine pathology. pathology.

Causes of Secondary Causes of Secondary dysmenorrheadysmenorrhea

Endometriosis: ectopic implantation of the Endometriosis: ectopic implantation of the endometrial tissue in other parts of the pelvic, endometrial tissue in other parts of the pelvic, it’s the most common cause of dysmenorrheait’s the most common cause of dysmenorrhea

Adenomiosis: ingrowth of the endometrium Adenomiosis: ingrowth of the endometrium into the uterine musculature.into the uterine musculature.

Fibroids Fibroids Pelvic infectionPelvic infection Intrauterine device Intrauterine device Cervical stenosisCervical stenosis Congenital uterine or vaginal abnormalitiesCongenital uterine or vaginal abnormalities

Clinical manifestationClinical manifestation sharp, intermittent spasm, usually in subrapupic sharp, intermittent spasm, usually in subrapupic

area.area. pain may radiate to the back of the leg or the pain may radiate to the back of the leg or the

lower backlower back systemic symptoms:systemic symptoms:1.1. nausea nausea 2.2. vomitingvomiting3.3. diarrheadiarrhea4.4. fatiguefatigue5.5. feverfever6.6. Headache or dizzinessHeadache or dizziness

Assessment:Assessment: Focused history and physical examination:Focused history and physical examination:1.1. in primary dysmenorrhea:in primary dysmenorrhea: cramping cramping

pain with menstruation and the physical pain with menstruation and the physical examination is completely normalexamination is completely normal

2.2. in secondary dysmenorrhea:in secondary dysmenorrhea: the history the history discloses cramping pain starting after 25 discloses cramping pain starting after 25 years old with pelvic abnormality.years old with pelvic abnormality.– history of infertilityhistory of infertility– heavy menstrual flowheavy menstrual flow– irregular cyclesirregular cycles– little or no response to NSAIDslittle or no response to NSAIDs

Assessment:Assessment:3.3. detailed sexual history to asses for inflammation detailed sexual history to asses for inflammation

or scaringor scaring4.4. bimanual pelvic examination in nonmenstrual bimanual pelvic examination in nonmenstrual

phase of the cyclephase of the cycle5.5. laboratory tests for: laboratory tests for: CBC to R/O anemiaCBC to R/O anemia Urine analysis to R/O bladder infectionUrine analysis to R/O bladder infection Pregnancy testPregnancy test Cervical culture to exclude STICervical culture to exclude STI ESR to detect an inflammatory processESR to detect an inflammatory process Pelvic and vaginal U/S Pelvic and vaginal U/S Diagnostic laprascopy or lapratomyDiagnostic laprascopy or lapratomy

Treatement:Treatement: pain relief : NSAIDs, cyclooxygenase- 2 pain relief : NSAIDs, cyclooxygenase- 2

inhibitorinhibitor hormonal contraceptives hormonal contraceptives life style changes:life style changes: daily ex.daily ex. limit salty foodslimit salty foods wt. losswt. loss smoking cessationsmoking cessation rekaxation techniquesrekaxation techniques

Dysfunctional uterine Dysfunctional uterine bleedingbleeding

is irregular, abnormal bleeding that is not caused by is irregular, abnormal bleeding that is not caused by pregnancy, a tumor or infectionpregnancy, a tumor or infection

( Bardeley, 2005). ( Bardeley, 2005). It occurs frequently at the beginning of and end of their It occurs frequently at the beginning of and end of their

reproductive years.reproductive years.With anovulation, estrogen levels rise as usual in the early With anovulation, estrogen levels rise as usual in the early

phase of the menstrual cycle. In absence of ovulation, a phase of the menstrual cycle. In absence of ovulation, a corpus luteum never forms and progesterone in not corpus luteum never forms and progesterone in not produced. The endometrium moves into a produced. The endometrium moves into a hyperproliferative state, this lead to irregular sloughing hyperproliferative state, this lead to irregular sloughing of the endometrium and excessive bleeding.of the endometrium and excessive bleeding.

Types of uterine bleeding Types of uterine bleeding disordersdisorders

Amenorrhea: (absence of menstruation)Amenorrhea: (absence of menstruation) Hypomenorrhea: (scanty menstruation)Hypomenorrhea: (scanty menstruation) Oligomenorrhea: (infrequent Oligomenorrhea: (infrequent

menstruation, periods more than 35 days menstruation, periods more than 35 days apart), Menorrhagia: (excessive apart), Menorrhagia: (excessive menstruation),menstruation),

Metrorrhagia: (bleeding between periods). Metrorrhagia: (bleeding between periods). Menometrorrhagia: (is heavy bleeding Menometrorrhagia: (is heavy bleeding

during and between menstrual periods).during and between menstrual periods).

Etiology:Etiology: adenomiosisadenomiosis pregnancypregnancy hormonal imbalancehormonal imbalance fibroid tumorsfibroid tumors endometrial polyps or cancerendometrial polyps or cancer EndometriosisEndometriosis

Etiology:Etiology: IUCDIUCD Polysystic ovary syndromePolysystic ovary syndrome Morbid obesityMorbid obesity Steroid therapySteroid therapy HypothyroidismHypothyroidism Clotting disordersClotting disorders

Clinical manifestation: Clinical manifestation: vaginal bleeding between periodsvaginal bleeding between periods irregular menstrual cycleirregular menstrual cycle infertilityinfertility mood swingsmood swings hot flasheshot flashes vaginal tendernessvaginal tenderness menstrual flow either scanty or profusemenstrual flow either scanty or profuse obesityobesity acneacne diabetes: insulin resistance is commondiabetes: insulin resistance is common

Assessment: Assessment: history takinghistory taking assist in pelvic examination to identify any assist in pelvic examination to identify any

structural abnormalitiesstructural abnormalities laboratory tests:laboratory tests:1.1. CBC to reveal anemiaCBC to reveal anemia2.2. PT to detect blood disordersPT to detect blood disorders3.3. BHCG to rule out abortion or ectopic pregnancyBHCG to rule out abortion or ectopic pregnancy4.4. TSH to screens for hypothyroidismTSH to screens for hypothyroidism Transvaginal ultrasound to measure endometrium Transvaginal ultrasound to measure endometrium Pelvic ultrasoundPelvic ultrasound Endometrial biopsy to check intrauterine pathologyEndometrial biopsy to check intrauterine pathology D&C for diagnostic evaluationD&C for diagnostic evaluation

Treatment: Treatment: it depend on the cause and age of the clientit depend on the cause and age of the client medical care with pharmacotherapy:medical care with pharmacotherapy:1.1. estrogen: cause vasospasm of the uterine estrogen: cause vasospasm of the uterine

arteries to decrease bleedingarteries to decrease bleeding2.2. cyclic progesterone or long acting cyclic progesterone or long acting

progesterone progesterone 3.3. oral contraceptives: regulate the cycle and oral contraceptives: regulate the cycle and

suppress the endometriumsuppress the endometrium4.4. NSAIDs inhibit prostaglandin NSAIDs inhibit prostaglandin 5.5. Iron replacement Iron replacement

Treatment:Treatment: if the client doesn’t respond to if the client doesn’t respond to

medical therapy:medical therapy:1.1. D&CD&C2.2. Endometrial ablation: is an Endometrial ablation: is an

alternative to hysterectomyalternative to hysterectomy3.3. Thermal balloon to ablate the Thermal balloon to ablate the

endometriumendometrium

Management:Management: Educate the client about normal Educate the client about normal

menstrual cycle and the possible menstrual cycle and the possible causes for her abnormal patterncauses for her abnormal pattern

Inform the woman about treatment Inform the woman about treatment optionoption

Inform her about any prescribed Inform her about any prescribed medicationmedication

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

Nursing management:Nursing management: It may result in the following complication:It may result in the following complication:1.1. infertility from lack of ovulationinfertility from lack of ovulation2.2. anemia from prolonged bleedinganemia from prolonged bleeding3.3. endometrial cancer from prolonged build endometrial cancer from prolonged build

up of the endometrial lining without up of the endometrial lining without menstrual bleedingmenstrual bleeding

Adequate follow up and evaluation is Adequate follow up and evaluation is necessarynecessary

Premenstrual syndrome Premenstrual syndrome ( PMS( PMS))

The The premenstrual syndrome premenstrual syndrome (PMS) is a distinct (PMS) is a distinct clinical entity characterized by a cluster of clinical entity characterized by a cluster of physical and psychological symptoms limited physical and psychological symptoms limited to 3 to 14 days preceding menstruation and to 3 to 14 days preceding menstruation and relieved by onset of the menses. relieved by onset of the menses.

The incidence of PMS seems to increase with The incidence of PMS seems to increase with age. It is less common in women in their teens age. It is less common in women in their teens and 20s, and most of the women seeking help and 20s, and most of the women seeking help for the problem are in their mid-30s. for the problem are in their mid-30s.

Although the causes of PMS are poorly Although the causes of PMS are poorly documented, they probably are multifactorial. documented, they probably are multifactorial.

Clinical manifestation:Clinical manifestation: The physical symptoms of PMS include:The physical symptoms of PMS include:

– Painful and swollen breastsPainful and swollen breasts– Bloating, abdominal painBloating, abdominal pain– Headache Headache – Backache Backache

Psychologically, there may be:Psychologically, there may be:o DepressionDepressiono AnxietyAnxietyo IrritabilityIrritabilityo Behavioral changes.Behavioral changes.

Premenstrual dysphoric Premenstrual dysphoric disorder:disorder:

Is a psychiatric diagnosis that has Is a psychiatric diagnosis that has been developed to distinguish been developed to distinguish women whose symptoms are severe women whose symptoms are severe enough to interfere significantly with enough to interfere significantly with activities of daily living or in whom activities of daily living or in whom the symptoms are not relieved with the symptoms are not relieved with the onset of menstruation, as is the onset of menstruation, as is usually the case with PMS. usually the case with PMS.

ASSESSMENT: ASSESSMENT: Diagnosis focuses on identification of the symptom Diagnosis focuses on identification of the symptom

clusters by means of prospective charting for at least clusters by means of prospective charting for at least 3 months.3 months.

A complete history and physical examination are A complete history and physical examination are necessary to exclude other physical causes of the necessary to exclude other physical causes of the symptoms.symptoms.

Depending on the symptom pattern, blood studies, Depending on the symptom pattern, blood studies, including:including:

Thyroid hormonesThyroid hormones Glucose tests may be done.Glucose tests may be done. Psychosocial evaluation is helpful to exclude Psychosocial evaluation is helpful to exclude

emotional illness that is merely exacerbated emotional illness that is merely exacerbated premenstrually.premenstrually.

TREATMENT:TREATMENT: Lifestyle changes: Lifestyle changes:

– An integrated program of regular exercise 3-5 An integrated program of regular exercise 3-5 times each week.times each week.

– Reduce stressReduce stress– avoidance of caffeineavoidance of caffeine– A diet emphasizing complex carbohydrates A diet emphasizing complex carbohydrates

and increase water intake. Foods high in and increase water intake. Foods high in simple sugars should be avoided simple sugars should be avoided

– Limit intake of alcohol.Limit intake of alcohol.– Stop smokingStop smoking

TREATMENT:TREATMENT: Vitamins and mineral supplements:Vitamins and mineral supplements:1.1. Multivitamin dailyMultivitamin daily2.2. Vitamin E,400units dailyVitamin E,400units daily3.3. Calcium, 1,200mg dailyCalcium, 1,200mg daily4.4. Magnesium, 200-400mg daily Magnesium, 200-400mg daily

TREATMENT:TREATMENT:Drug therapy should be used cautiously:Drug therapy should be used cautiously:

1.1. NSAIDs taken a week prior to NSAIDs taken a week prior to mensesmenses

2.2. Oral contraceptives ( low doses)Oral contraceptives ( low doses)3.3. AntidepressantsAntidepressants4.4. Anxiolytics Anxiolytics 5.5. DiureticsDiuretics