Disorders of menstruation

female reproductive disorders

1. DISORDERS OF MENSTRUATION

2. AMENORRHOEA

3. Introduction: Amenorrhoea is the absence of a menstrual period in a woman of reproductive age.

4. Physiological states of amenorrhoea are seen, most commonly, during pregnancy and lactation (breastfeeding), the latter also forming the basis of a form of contraception known as the lactational amenorrhoea method. Outside of the reproductive years there is absence of menses during childhood and after menopause.

5. Classification of amenorrhoea : Primary amenorrhoea (menstrual cycles never starting) may be caused by developmental problems such as, the congenital absence of the uterus, failure of the ovary to receive or maintain egg cells .

6. It is defined as an absence of secondary sexual characteristics by age 14 with no menarche or normal secondary sexual characteristics but no menarche by 16 years of age.

7. Secondary amenorrhoea (menstrual cycles ceasing) is often caused by hormonal disturbances from the hypothalamus and the pituitary gland, from premature menopause or intrauterine scar formation. It is defined as the absence of menses for three months in a woman with previously normal menstruation or nine months for women with a history of oligomenorrhoea .

8. Causes and risk factors: 1. Natural amenorrhea During the normal course of life , women may experience amenorrhea for natural reasons, such as: Pregnancy Breast-feeding Menopause

9. 2. Contraceptives Some women who take birth control pills may not have periods. Even after stopping oral contraceptives, it may take some time before regular ovulation and menstruation return. Contraceptives that are injected or implanted also may cause amenorrhea, as can some types of intrauterine devices.

10. 3. Medications Certain medications can cause menstrual periods to stop, including some types of: Antipsychotics Cancer chemotherapy Antidepressants Blood pressure drugs Allergy medications

11. 4. Lifestyle factors Sometimes lifestyle factors contribute to amenorrhea, for instance: Low body weight. Excessively low body weight — about 10 percent under normal weight — interrupts many hormonal functions in your body, potentially halting ovulation. Women who have an eating disorder, such as anorexia or bulimia, often stop having periods because of these abnormal hormonal changes.

12. Excessive exercise. Women who participate in activities that require rigorous training, such as ballet, may find their menstrual cycles interrupted. Several factors combine to contribute to the loss of periods in athletes, including low body fat, stress and high energy expenditure.

13. Stress. Mental stress can temporarily alter the functioning of your hypothalamus — an area of your brain that controls the hormones that regulate your menstrual cycle. Ovulation and menstruation may stop as a result. Regular menstrual periods usually resume after your stress decreases.

14. 5. Hormonal imbalance Many types of medical problems can cause hormonal imbalance, including: Polycystic ovary syndrome (PCOS). PCOS causes relatively high and sustained levels of hormones, rather than the fluctuating levels seen in the normal menstrual cycle.

15. Thyroid malfunction. An overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea.

16. Pituitary tumor. A noncancerous (benign) tumor in your pituitary gland can interfere with the hormonal regulation of menstruation.

17. Premature menopause. Menopause usually begins around age 50. But, for some women, the ovarian supply of eggs diminishes before age 40, and menstruation stops.

18. 6. Structural problems Problems with the sexual organs themselves also can cause amenorrhea. Examples include: Uterine scarring. Asherman's syndrome, a condition in which scar tissue builds up in the lining of the uterus, can sometimes occur after a dilation and curettage (D&C), cesarean section or treatment for uterine fibroids. Uterine scarring prevents the normal buildup and shedding of the uterine lining.

19. Lack of reproductive organs. Sometimes problems arise during fetal development that lead to a girl being born without some major part of her reproductive system, such as her uterus, cervix or vagina. Because her reproductive system didn't develop normally, she can't have menstrual cycles.

20. Structural abnormality of the vagina. An obstruction of the vagina may prevent visible menstrual bleeding. A membrane or wall may be present in the vagina that blocks the outflow of blood from the uterus and cervix.

21. Signs and symptoms: The main sign of amenorrhea is the absence of menstrual periods . Depending on the cause of amenorrhea, you might experience other signs or symptoms along with the absence of periods, such as: Milky nipple discharge Hair loss

22. Headache Vision changes Excess facial hair Pelvic pain Acne Vaginal dryness Night sweats

23. Diagnostic evaluation: History collection Physical examination Blood tests may be performed to determine the levels of hormones secreted by the pituitary gland (FSH, LH, TSH, and prolactin ) and the ovaries (estrogen). 

24. Ultrasonography of the pelvis may be performed to assess the abnormalities of the genital tract or to look for polycystic ovaries. CT scan or MRI of the head may be performed to exclude pituitary and hypothalamic causes of amenorrhea.

25. If the above tests are inconclusive, additional tests may be performed including: Thyroid function tests Determination of prolactin levels Hysterosalpingogram (X-ray test) which examine the uterus Hysteroscopy

26. Management: Dopamine agonists such as bromocriptine ( Parlodel ) or pergolide ( Permax ), are effective in treating hyperprolactinemia . In most women, treatment with dopamine agonists medications restores normal ovarian endocrine function and ovulation. Hormone replacement therapy consisting of an estrogen and a progestin can be used for women in whom estrogen deficiency remains because ovarian function cannot be restored.

27. Metformin ( Glucophage ) is a drug that has been successfully used in women with polycystic ovary syndrome to induce ovulation.

28. In some cases, oral contraceptives may be prescribed to restore the menstrual cycle and to provide estrogen replacement to women with amenorrhea who do not wish to become pregnant. Before administering oral contraceptives, withdrawal bleeding is induced with an injection of progesterone or oral administration of 5-10 mg of medroxyprogesterone ( Provera ) for 10 days.

29. Some pituitary and hypothalamic tumors may require surgery and, in some cases, radiation therapy. Women with intrauterine adhesions require dissolution of the scar tissue.

30. PREMENSTRUAL SYNDROME (PMS)

31. Introduction: Premenstrual syndrome (PMS) refers to physical and emotional symptoms that occur in the one to two weeks before a woman's period. Symptoms often vary between women and resolve around the start of bleeding.

32. Common symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes. Often symptoms are present for around six days. Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS that has greater psychological symptoms.

33. Causes and risk factors: Exactly what causes premenstrual syndrome is unknown, but several factors may contribute to the condition: Cyclic changes in hormones. Signs and symptoms of premenstrual syndrome change with hormonal fluctuations and disappear with pregnancy and menopause.

34. Chemical changes in the brain. Fluctuations of serotonin, a brain chemical (neurotransmitter) that is thought to play a crucial role in mood states, could trigger PMS symptoms. Insufficient amounts of serotonin may contribute to premenstrual depression, as well as to fatigue, food cravings and sleep problems.

35. Clinical manifestations: Emotional and behavioral symptoms Tension or anxiety Depressed mood Crying spells Mood swings and irritability or anger

36. Appetite changes and food cravings Trouble falling asleep (insomnia) Social withdrawal Poor concentration

37. Physical signs and symptoms Joint or muscle pain Headache Fatigue Weight gain related to fluid retention Abdominal bloating Breast tenderness Acne Constipation or diarrhea

38. Diagnostic evaluation: There are no unique physical findings or laboratory tests to positively diagnose premenstrual syndrome.

39. Management: Antidepressants. Selective serotonin reuptake inhibitors (SSRIs) — which include fluoxetine (Prozac, Sarafem ), paroxetine (Paxil, Pexeva ), sertraline (Zoloft) and others — have been successful in reducing mood symptoms. SSRIs are the first line treatment for severe PMS or PMDD. These drugs are generally taken daily. But for some women with PMS, use of antidepressants may be limited to the two weeks before menstruation begins.

40. Nonsteroidal anti-inflammatory drugs (NSAIDs). Taken before or at the onset of your period, NSAIDs such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, Naprosyn , others) can ease cramping and breast discomfort.

41. Diuretics. When exercise and limiting salt intake aren't enough to reduce the weight gain, swelling and bloating of PMS, taking water pills (diuretics) can help your body shed excess fluid through your kidneys. Spironolactone ( Aldactone ) is a diuretic that can help ease some of the symptoms of PMS.

42. Hormonal contraceptives. These prescription medications stop ovulation, which may bring relief from PMS symptoms.

43. Modify diet: Eat smaller, more-frequent meals to reduce bloating and the sensation of fullness. Limit salt and salty foods to reduce bloating and fluid retention. Choose foods high in complex carbohydrates, such as fruits, vegetables and whole grains. Choose foods rich in calcium. If you can't tolerate dairy products or aren't getting adequate calcium in your diet, a daily calcium supplement may help. Avoid caffeine and alcohol.

44. Incorporate exercise into regular routine Engage in at least 30 minutes of brisk walking, cycling, swimming or other aerobic activity most days of the week. Regular daily exercise can help improve your overall health and alleviate certain symptoms, such as fatigue and a depressed mood.

45. Reduce stress Get plenty of sleep. Practice progressive muscle relaxation or deep-breathing exercises to help reduce headaches, anxiety or trouble sleeping (insomnia). Try yoga or massage to relax and relieve stress.

46. Record symptoms for a few months Keep a record to identify the triggers and timing of your symptoms. This will allow you to intervene with strategies that may help to lessen them.

47. MENORRHAGIA:

48. Introduction: It is the most common type of abnormal uterine bleeding characterized by heavy and prolonged menstrual bleeding. In some cases, bleeding may be so severe and daily activities become interrupted.

49. A normal menstrual cycle 21-35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and blood of greater than 80 ml or lasting longer than 7 days constitutes menorrhagia .

50. Causes and risk factors: Hormone imbalance. In a normal menstrual cycle, a balance between the hormones estrogen and progesterone regulates the buildup of the lining of the uterus ( endometrium ), which is shed during menstruation. If a hormone imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.

51. Dysfunction of the ovaries. If ovaries don't release an egg (ovulate) during a menstrual cycle ( anovulation ), your body doesn't produce the hormone progesterone, as it would during a normal menstrual cycle. This leads to hormone imbalance and may result in menorrhagia .

52. Uterine fibroids. These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.

53. Polyps. Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual bleeding. Polyps of the uterus most commonly occur in women of reproductive age as the result of high hormone levels.

54. Adenomyosis . This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and painful menses.

55. Intrauterine device (IUD). Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. When an IUD is the cause of excessive menstrual bleeding, may need to remove it.

56. Pregnancy complications. A single, heavy, late period may be due to a miscarriage. If bleeding occurs at the usual time of menstruation, however, miscarriage is unlikely to be the cause. An ectopic pregnancy — implantation of a fertilized egg within the fallopian tube instead of the uterus — also may cause menorrhagia .

57. Cancer. Rarely, uterine cancer, ovarian cancer and cervical cancer can cause excessive menstrual bleeding.

58. Inherited bleeding disorders. Some blood coagulation disorders — such as von Willebrand's disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.

59. Medications. Certain drugs, including anti-inflammatory medications and anticoagulants, can contribute to heavy or prolonged menstrual bleeding.

60. Other medical conditions. A number of other medical conditions, including pelvic inflammatory disease (PID), thyroid problems, endometriosis, and liver or kidney disease, may be associated with menorrhagia .

61. Clinical Manifestations: Soaking through one or more sanitary pads or tampons every hour for several consecutive hours Needing to use double sanitary protection to control your menstrual flow Needing to wake up to change sanitary protection during the night

62. Bleeding for longer than a week Passing blood clots with menstrual flow for more than one day Restricting daily activities due to heavy menstrual flow Symptoms of anemia, such as tiredness, fatigue or shortness of breath.

63. Diagnostic evaluation: History collection Physical examination Blood tests. A sample of your blood may be evaluated for iron deficiency (anemia) and other conditions, such as thyroid disorders or blood-clotting abnormalities.

64. Pap test. In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer. Endometrial biopsy. Your doctor may take a sample of tissue from the inside of your uterus to be examined by a pathologist.

65. Ultrasound scan. This imaging method uses sound waves to produce images of your uterus, ovaries and pelvis. Based on the results of your initial tests, doctor may recommend further testing, including:

66. Sonohysterogram . During this test, a fluid is injected through a tube into your uterus by way of your vagina and cervix. Your doctor then uses ultrasound to look for problems in the lining of your uterus. Hysteroscopy. This exam involves inserting a tiny camera through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus.

67. Management: Iron supplements. If you also have anemia, your doctor may recommend that you take iron supplements regularly. If your iron levels are low but you're not yet anemic, you may be started on iron supplements rather than waiting until you become anemic.

68. Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps ( dysmenorrhea ).

69. Tranexamic acid. Tranexamic acid ( Lysteda ) helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding.

70. Oral contraceptives. Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.

71. Oral progesterone. When taken for 10 or more days of each menstrual cycle, the hormone progesterone can help correct hormone imbalance and reduce menorrhagia .

72. The hormonal IUD ( Mirena ). This intrauterine device releases a type of progestin called levonorgestrel , which makes the uterine lining thin and decreases menstrual blood flow and cramping.

73. Dilation and curettage (D&C). In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.

74. Uterine artery embolization . For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply.

75. Focused ultrasound ablation. Similar to uterine artery embolization , focused ultrasound ablation treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.

76. Myomectomy . This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions ( laparoscopically ), or through the vagina and cervix ( hysteroscopically ).

77. Endometrial ablation. Using a variety of techniques, doctor permanently destroys the lining of your uterus ( endometrium ). After endometrial ablation, most women have much lighter periods.

78. Endometrial resection. This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn't recommended after this procedure.

79. Hysterectomy. Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. Hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy ) may cause premature menopause.

80. Summary

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