GROUP IV.pptxbbbbbbbbbbbbbbbbbbbbbbbbbbbbb

women health

1. MODULES: WOMEN’S HEALTH LECTURE: ADRIEN CHRIS KANAKUZE GROUP IV ASSIGNMENT GROUP MEMBERS NAMES REGISTRATION NUMBERS Louise KAMANYANA 023/09/MDW/1666 Seraphine MUKABISANGWA 023/09/MDW/1581 Jean Remy ISHIMWE 023/09/MDW/1595 Assoumpta MUJAWAMRIYA 023/09/MDW/1606 Anne UWAMAHORO 023/09/MDW/1575 Josephine NIYIGENA 023/09/MDW/1573

2. MENSTRUATION DISORDERS

3. Objectives Recognize the characteristics of Normal Menstrual Bleeding Understand etiologies pathophysiology of AUB Understand the diagnostic tools of the AUB. State the medical & surgical options available in primary care .

4. INTRODUCTION Menstruation disorders encompass a variety of conditions that can affect the normal menstrual cycle. Your menstrual cycle is how your body prepares for pregnancy each month. Disorders associated with the menstrual cycle are amongst the most common complaints seen in primary care.

5. 1. DYSMENORRHEA Dysmenorrhea is Painful menstruation. Pain is usually located in the suprapubic area or lower abdomen. Women describe the pain as sharp, cramping, or gripping or as a steady dull ache

6. CONT’ It Can be divided into primary or secondary dysmenorrhea Primary dysmenorrhea is a condition associated with ovulatory cycles Pathophysiology During endometrial sloughing, endometrial cells release prostaglandins as menstruation begins

7. Cont ’ Prostaglandins stimulates myometrial contractions and ischemia Women with severe dysmenorrhea have higher levels of prostaglandins in menstrual fluid and these levels are highest during the first 2days of menstruation Primary dysmenorrhea usually appears 6 to 12 months after menarche when ovulation is established 5/17/24 8

8. RISKS FOR PRIMARY DYSMENORRHEA Earlier age at menarche Long menstrual periods Smoking Increased body mass index( BMI) In contrast parity appears to improve symptoms. 8/10/2018 9

9. Associated symptoms: Nausea, vomiting, Altered bowel habits, Headaches, Fatigue (prostaglandin-associated) Investigations Ultrasound to exclude pelvic lesions Hormonal profile

10. MANAGEMENT OF PRIMARY DYSMENORRHEA First choice : 80% respond to therapy with NSAIDs started 24-48 hours before the onset of pain. Ibuprofen PO 400 mg TDS / day for 3 days Naproxen : 500mg initially then 250mg every 6-8 hours Mefenamic acid ( Ponstel ) 500mg initially then 250mg every 6 hrs

11. Cont ’ Steroid Hormone contraception -COCs( combination oral contraceptives) -Progestin only contraceptive -Depot medroxyprogesterone acetate injection 5/17/24 12

12. Cont ’ Complementary and alternative medicine : Massaging the lower back can reduce pain by relaxing paravertebral muscles and increasing the pelvic blood supply Exercise helps relieve menstrual discomfort through increased vasodilation  Maintaining good nutrition at all times, specific dietary changes are helpful. 5/17/24 13

13. SECONDARY DYSMENORRHEA(SD) It is acquired menstrual pain that develops later in life than primary dysmenorrhea. Menstrual pain due to organic disease This condition is associated with pelvic pathology, such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps and menstrual outlet obstruction. In contrast to primary dysmenorrhea, the pain of secondary dysmenorrheal is often characterized by dull, lower abdominal aching radiating to the back or thighs. Often women experience feelings of bloating or pelvic fullness. Usually begins in women who are in their 20s, worsens with age .May improve temporarily after childbirth

14. SD con,t For this reason, SD may be associated with other gynecologic symptoms such as : Dyspareunia Dysuria Abnormal bleeding Or infertility

15. SD con,t Menstrual pain due to organic disease Usually begins in women who are in their 20s, worsens with age .May improve temporarily after childbirth Diagnosis physical examination with a careful pelvic examination, diagnosis may be assisted by ultrasound examination, endometrial biopsy, or laparoscopy.

16. MANAGEMENT Treat the underlying condition (surgery, endometriosis IUD) NSAIDs: Aspirine 300-600mg PO TDS start 1or 2 days before the menstruation Summary Primary Dysmenorrhea Menstrual pain in absence of organic disease. Secondary Dysmenorrhea Menstrual pain due to organic disease.

17. 2. PREMENSTRUAL SYNDROME Definition: Premenstrual syndrome (PMS) is a collection of physical, emotional, and behavioral symptoms that occur in the days leading up to menstruation. PMS affects many women to varying degrees, with symptoms typically resolving shortly after the start of menstruation

18. RISK FACTORS Hormone changes over a normal menstrual cycle. Stress Nutritional Factors: Poor diet, including excessive consumption of caffeine, alcohol, or sugar, can worsen PMS symptoms. Lifestyle Factors: Lack of exercise, poor sleep habits, and smoking,.. Underlying Health Conditions: Women with a history of depression, anxiety, or other mood disorders.

19. SIGNS AND SYMPTOMS Most women will experience at least one of menstrually related symptoms Physical, Emotional and Behavioral changes Anxiety Irritability Social, family, or occupational disruption Backache

20. CONT’ Violence Headache Aggression Breast tenderness/swelling Fatigue Depression and Loss of concentration Food craving Anorexia Mood change

21. MANAGEMENT Non-hormonal therapy Yoga • Music therapy • Self-help groups, stress management technics Health eating habits Hormonal therap y Progesteron supplement Commbined oral contraceptives pills )

22. 3. AMENORRHOREA The absence or stopping of menstruation and is frequently divided into primary and secondary amenorrhorea . Primary amenorrhea No menses by age 14 in absence of 2 secondary sexual characteristics or no menses by age 16 with secondary sexual characteristics.

23. PRIMARY AMENORRHOREA Differential Diagnosis of Amenorrhea. Hypothyroidism Hyperprolactinemia PCOS Hypothalamic dysfunction Anatomic abnormalities Müllerian agenesis, uterovaginal septum, imperforate hymen

24. Classification system One useful scheme divides the causes of amenorrhea into Anatomic and Hormonal. 5/17/24 25

25. SECONDARY AMENORRHOREA Cessation or stopping of menstruation for a period equivalent to a length of 3 consecutive cycles or 6 months. secondary amenorrhea is pregnancy until proven otherwise. exercise and/or anorexia) is the most common cause of amenorrhea. Functional hypothalamic amenorrhea (often related to stress excessive

26. CAUSES Pregnancy and lactation Menopause Hythalamo-putuitary (Inflammatory, neoplastic, Traumatic) Stress Anxiety Excessive loss of weight Contraceptives Polycystic ovarian syndrome (PCOS) Traumatic curettage, Post partum infection 

27. SIGNS AND SYMPTOMS At least 3 consecutive cycles of absence of menses History of curretage , post partum infection Galactorrhea Premature monapause Obesity Headache,..

28. INVESTIGATIONS Hormonal profile Pregnancy test Ultrasound Thyroid test X ray of the skull ( turcique selle : Pituitary) Pituitary tumor or necrosis CT scan

29. MANAGEMENT Etiologic treatment Hormonal treatment: Polycystic ovarian syndrome: cyclic progesterone treatment or oral contraceptives or other forms of estrogen- progesteron treatment. hyperandrogenism due to PCOs may be treated with oral contraceptives and/or spironolactone. Surgical treatment: Anatomic abnormalities Infertility: require medical or surgical management Patient education to n ormalize the Body Mass Index

30. 4 . ABNORMAL UTERINE BLEEDING (AUB) Def:Any change happening in the menstrual cycle parameters, Flow Duration Frequency Bleeding between cycles Prevalence: 25% of visits to gynecologists

31. Terminology Metrorrhagia Menometrorrhagia Polymenorrhea Oligomenorrhea Hypomenorrhea Acute AUB : refers to an episode of heavy uterine bleeding that, is of sufficient to require immediate intervention to prevent further blood loss Chronic AUB : uterine bleeding which is present for most than 6 months Intermenstrual Bleeding

32. Normal menstrual cycle Normal parameters: Cycle interval: 21 – 35 days Menses: 4 – 7 days Blood loss: 30 – 45 mL

33. Abnormal uterine bleeding Bleeding that occurs outside the normal parameters of the menstrual cycle (volume, duration, or interval) Cycle interval: length 21 – 35 days,duration4–7days;volum: 30 – 45 mL Abnormal Uterine Bleeding (AUB): Polymenorrhea : regular cycle interval< 21 days Oligomenorrhea: irregular cycle interval >35d Menorrhagia: regular blood loss > 80 mL or menses > 7 days

34. Cont ’ Metrorrhagia: Metrorrhagia is a medical term used to describe irregular, non-menstrual bleeding that occurs between menstrual periods or after menopause.

35. Etiology of AUB: FIGO ;Classification System 2011 PALM-COEIN: Structural vs. Non-Structural causes OR orgnanic ><non organic

36. PALM Structural Causes P- Polyp (AUB-P) A - Adenomyosis (AUB-A) L- Leiomyoma (AUB-L) Submucosal myoma (AUB-L SM ) Other myoma (AUB-L O ) M - Malignancy & hyperplasia (AUB-M)

37. COEIN Non-Structural Causes C- Coagulopathy (AUB-C) O- Ovulatory dysfunction (AUB-O) E- Endometrial (AUB-E) I- Iatrogenic (AUB-I) N- Not yet classified (AUB-N

38. Etiology of AUB life cycle approach Adolescence : AUB can be caused by factors such as anovulatory cycles (cycles without ovulation), hormonal imbalances during puberty, or conditions like polycystic ovary syndrome (PCOS) that affect menstrual regularity. Reproductive Years: In women of reproductive age, common causes of AUB include uterine fibroids (leiomyomas), adenomyosis, endometrial polyps, hormonal imbalances, pelvic inflammatory disease (PID), or complications related to pregnancy or childbirth.

39. Cont ’ Perimenopause: During the transition to menopause, fluctuations in hormone levels, changes in menstrual cycle regularity, and conditions like endometrial hyperplasia or fibroids can contribute to AUB in perimenopausal women. Postmenopause : AUB can be a concerning sign as it may indicate underlying conditions such as endometrial atrophy, endometrial hyperplasia, or even endometrial cancer. Other causes may include hormone replacement therapy or certain medications.

40. AUB: Evaluation History: Menstrual history (volume, duration, intervals) Associated symptoms e.g. dysmenorrhea, post-coital bleeding Medical history and medications Pelvic Exam Cervical and vaginal lesions Size, shape of uterus

41. Evaluation Laboratory Urine pregnancy test CBC with platelets Coagulation studies Thyroid studies (TSH, T4) Prolactin Diagnostic Procedures Pap smear Endometrial biopsy (EMB) Transvaginal ultrasound Hysteroscopy

42. EVALUATION OF AUB( Figo ) YES NO

43. AUB: management Treat the underlying cause with relief of volume and duration of menses ,BUT RULE OUT PREGNANCY and MALIGNANCY Medical management NSAID’s OCP’s Levonorgestrel IUD ( Mirena ) GnRH agonists (e.g. Lupron ) Correct medical condition

44. AUB: surgical management Endometrial ablation no fertility desire D&C - IF clinically indicated Myomectomy – IF leiomyomata and fertility desired Hysteroscopic resection – IF polyp, submucous myoma Hysterectomy (TAH, TVH, or TLH)

45. ii. DYSFONCTIONAL UTERINE BLEEDING (DUB) DUB refers to abnormal uterine bleeding that occurs due to hormonal imbalances without any identifiable structural or systemic cause ( COEIN) Abnormal uterine bleeding which is not attributed to an organic cause or pathology (PALM)

46. DUB. Etiology Anovulation , Ovulation failure is the most common type of DUB in adolescents and in women who are reaching perimenopause . Polycystic ovary syndrome (PCOS) Obesity

47. DUB. Who is at risk? Overweight,(BMI 25-30) because hormones involved in ovulation aren’t available from fat stores • Exercise excessively, because they don’t have enough body fat to maintain a menstrual cycle • Under stress • PCOS

48. DUB Evaluation Pelvic Exam Cervical and vaginal lesions Size, shape of uterus Laboratory evaluation Urine pregnancy test(reproductive age women) CBC with platelets Coagulation studies Thyroid studies (TSH, T4) DHEAS and testosterone, if symptoms of hirsutism Prolactin Procedures Endometrial biopsy (R/O neoplasia ) Transvaginal ultrasound (R/O anatomic lesions)

49. DUB: Medical management Massive Intractable Bleeding: Conjugated Estrogens 25 mg IV // 6h when decreases followed by oral E2 OR Continued Management after Massive Bleeding Conjugated Estrogens 2.5 mg po daily x 25 days Medroxyprogesterone acetate 10 mg for the last 10 days Administer Mirena IUD

50. Management of Moderate Menometrorrhagia 1.Estrogen-Progestin Combination Conjugated Estrogen 1.25 mg po daily x 20 days + Medroxyprogesterone acetate 10 mg po for last 10 days OCP x 21 days, with 7 day withdrawal 2.Cyclic Progestin Medroxyprogesterone acetate 10 mg po daily x 10-15 days ea. Month .16e 25e D 3.Mirena IUD

51. Arachidonic Acid Prostaglandins Thromboxane Prostacyclin* *Causes vasodilation and inhibits platelet aggregation Management con’t In case of ovulation-related AUB, (NSAIDs), such as naproxen, ibuprofen, or mefenamic acid, to decrease blood loss NSAIDs decrease PGs production ,decreasing blood flow and pain.. D&C Is now performed only to treat hemorrhage that doesn’t respond to medical therapy.

52. DUB: surgical management Who? Patients who do not respond to medical therapy Patients who do not desire future pregnancies Management: Endometrial ablation Hysterectomy without oophorectomy

53. References APGO Medical Student Educational Objectives , 9 th edition, (2009), Educational Topic 45 (p96-97). Beckman & Ling: Obstetrics and Gynecology , 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky , William NP Herbert, Douglas W  Laube , Roger P Smith. Chapter 35 (p315-319). Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology , 5th edition (2009) , Neville F Hacker, Joseph C Gambone , Calvin J Hobe l . Chapter 33 (p368-370).