Disorders of menstruation, for women 2.pptx

Disorder of menstruation

1. Disorders of menstruation Md 3 management of disease January 2022

2. Objectives Menorhagia Dysmenorrhoe Amenorrhoea / oligomenorihoe Polycystic ovarian syndrome Premenstrual syndromes Postmenopausal bleeding

3. introduction • Disorders of menstrual cycle – most common reason for women to attend to gynecologist • Psychological & Occupational disrruption understand normal menstrual physiological •Approach – should compassionate & empathetic manner

4. MENORRHAGIA- heavy/excessive menstrual loss - Loss > 80mL/ per period Normal menstruation: > average = 3 – 7 days >Mean blood loss 35 mLs

5. MENORRHAGIA - INCIDENCE Incidence: 5% of warm age 30 t0 49 years cause for referal

6. MENORRHAGIA Classification Idiopathic - no organic pathology (DUB) majority of woman with menorrhagia will have with “DUB” Secondary = organic cause found eg fibroids

7. MENORHAGIA Aetiology - not clear - Prostglandins – implicated - Abnormalities of endometrial vascular development. - Family size – number of menstrual cycles - delayed conception

8. MENORRHAGIA Etiology ctd Bleeding diathesis Fibroid Endometrial polyp Thyroid disease IUCD Drugs Bleeding in pregnancy

9. MENORRHAGIA Clinical Features History: excessive menstrual loss occurring over several consecutive cycles No, pads / towels 50% of woman who complain of heavy periods – the actual blood loss does no correspond

10. MENORRHAGIA Clinical exam - Physical exam – abdomen + pelvic exam - Cervical smear should be performed - Estimation of blood loss

11. MENORRHGIA Initial investigation --FBP to ascertain a need for iron therapy For failure to respond to iron therapy -Transvaginal USS =Endometrial Biopsy

12. MENORRHGIA -TREATMENT Medical treatment for menorrhagia Gp 1- (Compatible with on going attempt at conception Mefenamic acid & other NSAID Tranexam = ic acid Gp 2: Incompatible with attempts @ Conception DanaZol GP3 Licensed for contraception & effective as treatment for menorrhagia’ COC LNG = IUS

13. MENORRHAGIA - TREATMENT Mefenamic acid -NSAID Associated with significant reduction of blood loss -Mode of action – restoring imbalanced endometrial prostaglandin synthesis. -Added benefit treating dysmenorrhoea

14. MENORRHAGIA -TREATMENT Tranexamic acid Reduces MBL to about 50 – 100mls Mode of action – inhibits fibrinolysis in the endometrium

15. MENORRHAGIA – TREATMENT Danazol: 3 months treatment = MBL 100mls Side effect – androgenic effects – wt gain. acne and hursutism and voice changes Combined Oral Contraceptives (COC Widely used for Rx menorrhagia Many women are unreluctant to take coc

16. MENORRHAGIA - TREATMENT Levonorgestrel -IUCD {LNG – IUD} Revolutionized tr for eatment menorrhagia Effective up to 95% Alternative to surgical intervention (endometrial r esection) 30% of woman on LNG – IUD have normal menses by 3-6 months after insertion of LNG – IUD

17. MENORHAGIA - TREATMENT In use but, Not effective ) Ethamsylate Luteal phase progesterone Uterine curretage

18. MENORRHAGIA - SURGICAL MANAGEMENT Surgical management for menorrhagia Women contemplating surgical treatment for menorrhagia – certain that family is complete Woman wishing to conserve fertility should be advised to use LNG – IUD

19. MENORRHAGIA - SURGICAL MANGEMENT Endometrial oblation : Endometrial destructive procedures depths is sufficient to prevent generation of endometrium. Methods performed under hysterescopy   Hysterectomy Removal of uterus Can be total or subtotal, with or without bilaleral SOP

20. MENORRHAGIA - SURGICAL MANAGENT -BSOP reduces the risk of ovarian cancer, but exposes the woman to adverse effect of oestrogen loss (bone density) -Removal of ovarian without full explanation/understanding is a recurrent cause of litigation - Modes of hysterectomy include : Abdominal hysterectomy Vaginal hysterectomy

21. DYSMENORRHOEA

22. DYSMENORRHOEA – DEFINITION,PREVALENCE & CLASSIFICTION Definitions – painful menstruation Prevalence Common, affects 45 – 95% of woman in reproductive age Classification: i ) Primary – (no organic pathology) ii) Secondary (with identifiable organic pathology

23. DYSMENORRHHOEA - AETIOLOGY Primary: - risk factors Menstrual flow. 5 days Younger than normal age at menarche Cigrete smoking dysmenorhoea improves after child birth Secondary: Symptoms of endometriosis, pelvic inflammatory or adenomyosis

24. DYSMENORRHOEA –PRESENTATION/INVESTIGATION Clinical presentations Crampy supra pubic pain, starting at onset of menstrual flow and lasting 8 – 72 hours. Investigations A history usually adequate to make a diagnosis of dyspmenorrhoe Absence of abnormal findings on examination it is reasonable to try treatment symptomatically

25. DYSMENORRHOEA - TREATMENT NSAID e.g. Iboprufen , mefenamic acid Oral contraceptive – little evidence, but widely used Nifedipine – used in treatment of dysmenorrhoea Surgical treatment – interrupting the nerve supply from uterus have been employed.

26. AMMENORRHOE

27. AMENORRHOEA - INTRODUCTION At least five basic factors involved in onset and continuation of normal menstruation. Normal female chromosomal pattern (46XX). Coordinated hypothalamopituitary ovarian axis. Anatomical presence and patency of the outflow tract. Responsive endometrium. Active support of thyroid and adrenal glands.

28. AMENORRHOEA - CLASSIFICATION failure of menses to occur by age 16 years or within 2 years of full secondary sexual characteristic development. (primary) absence of menstruation for 3 or more months during the reproductive years (secondary) most common causes of amenorrhea are physiologic (i.e.,> pregnancy, > lactational ) pathologic, amenorrhea may be caused by genetic, anatomic, ovarian failure, or endocrine disorders.

29. AMENORRHOEA - PHYSIOLOGICAL before Puberty pituitary gonadotropins are not adequate enough to stimulate the ovarian follicles for effective steroidogenesis → estrogen levels are not sufficient enough to cause bleeding from the endometrium. During Pregnancy estrogens and chorionic gonadotropins secreted from the trophoblasts suppress the pituitary gonadotropins → no maturation of the ovarian follicles.

30. AMENORRHOEA - PHYSIOLOGICAL During Lactation High level of prolactin → inhibits ovarian response to FSH → no follicular growth → hypoestrogenic state → no menstruation. If the patient does not breastfeed her baby, the menstruation returns by 6th week following delivery in about 40 % and by 12 th week 80 % of cases

31. AMENORRHOEA - PHYSIOLOGICAL Menopause No more responsive follicles are available in the ovaries for the gonadotropins to act. As a result, there is cessation of estrogen production from the ovaries with elevation of pituitary gonadotropins.

32. AMENORRHOEA – PATHOLOGICAL= CRYPTOMENORRHOEA Definitions a condition where the menstrual blood fails to come out from the genital tract due to obstruction in the passage. Causes Congenital - due to imperforate hymen. acquired - rare due to cervical stenosis following amputation, conization or deep cauterization.

33. CRYPTOMENORRHOEA Pathophysiology If the obstruction is low down in the vagina > the accumulated blood results in hematocolpos →hematometra → hematosalpinx . If the obstruction is at the cervix , > produce hematometra → hematosalpinx . Hematocolpos produces marked elongation of the urethra →retention urine.

34. CRYPTOMENORRHOEA - Clinical features patient aged about 13–15 complains of periodic pain lower abdomen. Hematocolpos is usually associated with urinary problem including retention of urine. Abd exam, reveals an unif orm globular mass in the hypogastrium. Vulval inspection reveals the bulging hymen. Rectal examination confirms the fullness of the vagina and uterine mass.

35. CRYPTOMENORRHOEA Management Cruciate incision of the hymen and drainage of blood . Dilatation of the cervix in stenosis.

36. PRIMARY AMENORRHOEA Causes: causes of primary amenorrhea are grouped as follows : Hypogonadotropic hypogonadism ( i ) Delayed puberty — delayed GnRH pulse reactivation. (ii) Hypothalamic and pituitary dysfunction —Gonadotropin deficiency due to stress, weight loss, excessive exercise, anorexia nervosa chronic disease (tuberculosis)

37. PRIMARY AMENORRHOEA - INVESTIGATION When to start investigation ( i ) No period by 16 years of age in the presence of normal secondary sex characters. (ii) No period by the age of 14 in the absence of growth or development of secondary sex characters. However, the formula may not be applicable in all cases

38. PRIMARY AMENORRHOE - CAUSES B. Hypergonadotropic hypogonadism ( i ) Primary ovarian failure . (ii) Resistant ovarian syndrome. C. Abnormal chromosomal pattern Turner’s syndrome (45 X) . Various mosaic states 45 X/46 XX. Pure gonadal dysgenesis (46 XX or 46 XY)

39. PRIMARY AMENORRHOEA -CAUSES D. Developmental defect of genital tract Imperforate hymen Transverse vaginal septum. Atresia upper-third of vagina and cervix E. Dysfunction of thyroid and adrenal cortex Adrenogenital syndrome

40. PENDING TOPICS POLYCYSTIC OVARIAN SYNDROME