Menstrual irregularities

Menstrual irregularities are the problems with a girl's normal monthly menses. For example, missed periods, have them too frequently, having painful periods, or have excessively heavy flow. Menstrual irregularities can sometimes be a sign of an underlying health problem.

1. SANDHYA KUMARI M.SC. NURSING AMITY UNIVERSITY MENSTRUAL IRREGULARITIES

2. INTRODUCTION Menstruation is the visible manifestation of cyclic physiologic uterine bleeding due to shedding of the endometrium following invisible interplay of hormones mainly through hypothalamo - pituitary- ovarian axis.

3. MENSTRUATION The development and maturation of a follicle, ovulation and formation of corpus luteum and its degeneration constitute an ovarian cycle. All these events occur within 4 weeks. The ovarian cycle consists of: Recruitment of groups of follicles. Selection of dominant follicle and its menstruation. Ovulation Corpus luteum formation Demise of corpus luteum .

4. MENSTRUAL IRREGULARITIES Menstrual irregularities are common abnormalities of a woman’s menstrual cycle. Menstrual irregularities include a variety of conditions in which menstruation is irregular, heavy, painful, or does not occur at all.

5. Common types of menstrual irregularities include: Amenorrhea Dysmenorrhea Menorrhagia Oligomenorrhea Polymenorrhea Spotting Pre menstrual syndrome Menopause Metorrhagia Dysfunctional uterine bleeding.

6. AMENORRHOEA Amenorrhoea means absence of menstruation. It is not a symptom and not a disease. 5 basic factors involved in the onset and continuation of normal menstruation. These are: Normal female chromosomal pattern(46XX). Co- ordinate hypothalamo -pituitary ovarian axis. Anatomical presence and patency of the outflow tract. Responsive endometrium . Active support of thyroid and adrenal glands. 

7. CLINICAL TYPES Physiological Primary (before puberty) Secondary -during pregnancy -during lactation -following menopause. Pathological Concealed ( cryptomenorrhoea ) Congenital acquired  real (true) primary secondary

8. PRIMARY AMENORRHOEA A young girl who has not yet menstruated by her 16 years of age is giving primary amenorrhoea rather than delayed menarche. The normal upper age limit for menarche is 15 years.

9. CAUSES: 1. Hypogonadotrophic hypogonadism Delayed puberty – delayed Gn RH pulse reactivation. Hypothalamic & pituitary dysfunction Kallmann’s syndrome – inadequate Gn RH pulse secreation - reduced FSH & LH. CNS tumors- craniopharyngioma - reduce Gn RH- Reduce FSH & LH.  2. Hypergonadotrophic hypogonadism Primary ovarian failure Resistant ovarian syndrome Galactosemia Enzyme edficiency (17 alpha hydroxylase deficiency) Others- gonadotrophin receptors mutations

10. 3. Abnormal chromosomal pattern Turner’s syndrome(45X) Pure gonadel dysgenesis (46XX or 46 XY) Androgen insensitivity syndrome ( testicular feminization syndrome) Partial deletion of X chromosome (46XX)   4. Developmental defect of genital tract Imperforate hymen Transverse vaginal septum Atresia upper third of vagina and cervix Complete absence of vagina

11. 5. Dysfuction of thyroid and adrenal cortex Adrenogenital syndrome cretinism 6. Metabolic disorders Juvenile diabetes 7. Systemic illness Malnutrition, anemia Weight loss Tuberculosis 8. Unresponsive endometrium Congenital (uterine synechiae - tubercular.

12. SPECIAL INVESTIGATIONS OF PRIMARY AMENORRHOEA Mullerian agenesis USG Laproscopy Karyotype   Unresponsive endometrium Progesterone challenge test HSG/ Hysteroscopy Hormonal studies

13.   Uterine synchiae Progesterone challenge test HSG hysteroscopy   tubercular blood- ESR X ray- chest Mantaoux test Endometrial biopsy  Hypogonadotrophic gonadism Progesterone challenge test Serum gonadotrophins Serum oestradiol

14. Primary ovarian failure Karyotype Serum oestradiol Serum gonadotrophin Ovarian biopsy Tumer Laproscopy Serum gonadotrophins Karyotype

15. Androgen insensitivity syndrome Laproscopy Serum testosterone Karyotype Gonadal biopsy Adrenogenital syndrome Karyotype Serum 17 hydroxy -progesterone Urinary pregnanetriol Thyroid dysfunction (hypo) Serum TSH T3, T4 Diabetes: RBS

16. This test is performed by administering inj. Progesterone in oil 75 mg IM or tab Medroxyprogesterone 10 mg daily or micronized progesterone 200mg daily for 10 days. Withdrawl bleeding usually occurs within 10 days, if the test is positive.

17. MANAGEMENT OF PRIMARY AMENORRHOA In primary amenorrhea: correct the underlying cause estrogen replacement therapy if pituitary tumor: treatment with surgical resection, radiation and drug therapy surgery to correct abnormalities of genital tract

18. SECONDRY AMENORRHOEA   Secondary amenorrhea: is the absence of menses for 3 cycles or 6 months in women who have previously menstruated regularly.   Causes: Breast feeding Emotional stress Mal nutrition, tuberculosis Pregnancy PCOS Premature ovarian failure Pituitary, ovarian, or adrenal tumour Depression Hyper thyroid or hypothyroid Diabetes Hyper prolactinemia Rapid wt gain or loss related to amenorrhoea

19. Kallmann syndrome post pill amenorrhoea Chemotherapy or radiotherapy Aneroxia nervosa Hypothalamic dysfunction- stress, exercise, rapid wt. gain or loss. Vigorous excrete Kidney failure Tranquilizers or antidepressant , anti hypertensives Post partum pituitary necrosis Early menopause

20.   Detailed history: Mode of onset- whether sudden or gradual preceded by hypomenorrhoea or oligomenorrhoea . Sudden changes in envt ., emotional, stress, psychogenic shock, eating disorders etc Sudden loss or gain weight Intake of psychotrophic or anti hypertensive drugs . Intake of oral pills or its recent withdrawl . h/o recent chemo or radiotherapy

21. Appearance of abnormal manifestations either by coinciding or preceeding the amenorrhoea . Acne, hirsutism or change in voice. Inappropriate lactation galactorrhoea .( abnormal secretion of milk unrelated to pregnancy and lactation. Headache and visual disturbances. Hot flushes and vaginal dryness Obstetric history- overzealous curettage leading to synechiae . Cessarrian section may be extended to hysterectomy of which the patient may be unaware. Severe PPH, shock, infection. Postpartum or postabortal uterine curettage Prolonged lactation Medical history of TB., Diabetes, chronic nephritis, hypothyroid. Family history- premature menopause in family.

22. General examination: Nutritional status Extreme emaciation or marked obesity Presence of acne, hirsutism Discharge of milk from breasts Abdominal examination Presence of striae associated with obesity may be related to Cushing syndrome. A mass in lower abdomen. Pelvic examination Enlargement of clitoris. Adnexal mass suggestive of tubercular tuboovarian mass or ovarian tumour .

23. Tests that can be done are: Progesterone challenging test Oestrogen - progesterone challenge test Serum gonadotrophins Gn RH dynamic test. CT MRI X-RAY

24. MANAGEMENT FOR SECONDARY AMMENORRHOEA 1. NO ABNORMALITY DETECTED If patient is not anxious, no treatment is required. Provide assurance. If she is anxious provide oral contraceptive pills to be continued for atleast 3 cycles. With low endogenous oestrogen : ethinyl oestradiol 0.02 mg or conjugated equine oestragen 1.25 mg daily is to be taken for 25 days. Medroxyprogesterone acetate 10 mg daily is added from day 16-25. The patient is anxious for fertility. Husbands semen analysis in primary infertility and the tubal factor of the women are to be evaluated prior to induction of ovulation either using clomiphene or gonadotrophins .

25. 2. CASES WITH DETECTABLE CAUSE Anxiety and stress- may be corrected by reassurance, psychotherapy. Improve health status

26. 3. POLYCYSTIC OVARIAN SYNDROME (PCOS) First correct the biochemical parameters such as : Hyperandrogenemia Hyperprolactenemia Hyperinsulinemia Insulin resistance High serum oestradiol Low FSH Low serum progesterone androgenic follicular microenvironment Weight reduction

27. If fertility not desired Management of hyperandrogenemia Combined oral contraceptive pills Antiandrogens such as cyproterone acetate, flutamide may be given. Metformin may be given as an oral insulin sensitizing agent. Endometrial biopsy can be done in case of endometrial hyperplasia. Cabergolin , bromocriptine in case of hype r prolactenemia (if failed surgery can be done as – transnasal-transsphenoidal adenectomy is done. If premature ovarian failure- HRT can be given ) Thyroxine ---- of hypothyroid state.

28. SURGERY Laproscopic ovarian drilling (LOD) Bariatric surgery in case of PCOS who are morbidly obese

29. PREMENSTRUAL SYNDROME (PMS) (Premenstrual tension) Premenstrual syndrome is a psychoneuroendocrine disorder of unknown etiology that occurs just prior to menstruation. There is a cyclic appearance of several symptoms during the last 7-10 days of the onset of menstrual cycle which subside the onset of menstrual flow. At least 5 of the symptoms must have been present in most of the cycles over the past one year. When these symptoms disrupt daily functioning they are grouped under premenstrual dysmorphic disorder (PMDD).

30. Clinical manifestation of PMS Depressed mood, hopelessness, and self depreciation. Anxiety, tension, fearfulness. Affective liability- mood swings Anger, irritability, interpersonal conflict. Decreased energy. Appetite changes or cravings. Changes in sleep. Feeling overwhelmed or out of control. Physical symptoms such as breast tenderness, headache. Dyspareunia , bloating. Weight gain.

31. PATHOPHYSIOLOGY The exact cause is not known but the following hypothesis is considered. Alteration in the level or ratio of oestrogen and progesterone from the mid luteal phase. Neuroendocrine factors: Decreased synthesis in the luteal phase. Withdrawl of endorphins from CNS during luteal phase. Psychological and psychogenic factors affecting behavior.

32. TREATMENT General   Elimination of caffeine from the diet. Avoidance of smoking, alcohol. Regular exercise. Regular meals and nutritious diet. Adequate sleep. Relaxation techniques like yoga, stress management and assurance. Alternative & complementary therapy.

33. Non hormonal Tranquilizers or antidepressant drugs Pyridoxine Diuretics in the second half of the cycle. Serotonin reuptake inhibitors such as fluoxetine .   Hormones Oral contraceptives pills to maintain a uniform hormonal melieu . Progestogen . Bromocriptine to relieve breast symptoms. Gn RH agonists to suppress gonadal steroids.

34. NURSING MANAGEMENT Encourage patient to set goals for the reduction of symptoms such as mood swings, crying, binge eating, and day to day stressors. Teach positive coping measures, involve and encourage family members such as spouse or children for assistance and care. Encourage use of exercise, meditation and creative activities to reduce stress. Provide instructions about the desired effects of prescribed medications.

35. DYSMENORRHOEA Dysmenorrhoea : painful menses or cramping during menstruation of sufficient magnitude so as to incapacitate day to day activities. Typically dysmenorrhoea begins upto 48 hours before the onset of menses and resolves within 2 to 4 days of onset or by the end of menstrual period.

36. TYPES OF DYSMENORRHOEA Primary dysmenorrhoea (spasmodic) Secondary dysmenorrhoea (congestive)

37. PRIMARY DYSMENORRHOEA ( spasmodic) It is painful menses with a uterine cause, but without pelvic pathology and usually occurs within 1-3 years of menarche. Cause: Painful uterine contractions stimulated by prostaglandin produced by the endometrium during menses are most often identified as the cause for primary dysmenorrhoea .

38. Others may be like- Mostly confined to adolescents. Almost always confined to ovulatory cycles. The pain is usually cured following pregnancy and vaginal delivery. The pain is related to dysrhythemic uterine contractions and uterine hypoxia. Psychogenic factors- of tension, anxiety lowers the pain threshold. Abnormal anatomical and functional aspect of myometrium like Uterine myometrial hyperactivity. Imbalance in the autonomic nervous control of uterine muscle. Role of prostaglandins. Role of vasopressin Platelet activating factors (PAF)  

39. Symptoms: Sharp, intermittent suprapubic pain radiating to the back or thigh. Headache, fatigue, backache, flushing, dizziness and syncope. Adolescents typically experience the problem only after menstrual cycles become ovulatory . Women often experience reduction in dysmenorrhoea after pregnancy.

40. THERAPEUTIC INTERVENTIONS   Nonsteriodal anti inflammatory drugs (NSAID) started 1-3 days prior to the onset of menstrual flow (to decrease prostaglandin production). Oral contraceptives, to decrease endometrial proliferation and therefore production of prostaglandin. Surgery: Transcutaneous electrical nerve stimulation (TENS) Laproscopic uterine nerve ablation(LUNA). Dilatation of cervical canal. Presacral neurotomy (LPSN).

41. SECONDARY DYSMENORRHOA (congestive)     Secondary dysmenorrhoea is painful menses resulting from a pathologic process. Cause: pressure from outside the uterus tissue ischemia cervical stenosis congenital abnormality ( imperfotate hymen) endometriosis ovarian cysts pelvic inflammatory disease (PID) uterine fibroid tumous . IUCD in utero and pelvic congestion. Obstruction due to mullerian malformation.

42. clinical features:     The pain is dull, situated in the back and in front without any radiation. It usually appears 3-5 days prior to the period and relieves with the start of bleeding. The onset and duration depends on the pathology producing the pain. There is no systemic discomfort unlike primary dysmenorrhoea . Other symptoms may be breast tenderness and change in bowel habits.

43. diagnostic evaluation: Laproscopy Hysteroscopy/ laparotomy TREATMENT The treatment aims at the cause rather than the symptom. The type of treatment depends on the severity, age and parity of the patient.

44.   OVARIAN DYSMENORRHOEA (RIGHT OVARIAN VEIN SYNDROME) Right ovarian vein crosses the ureter at right angle. During premenstrual period, due to pelvic congestion or increased blood flow, there may be marked engorgement in the vein –pressure on ureter- stasis- infection- pyelonephritis- pain.

45. MITTELSCHMERZ’S SYNDROME (ovular pain) Ovular pain is not an infrequent complaint. It appears in the midmenstrual period. The pain usually situated in the hypogastruism or in either iliac fossa . The pain is usually located at one side and does not change from from side to side according to which ovary is ovulating. Nausea or vomiting is conspicuously absent. It rarely last for 12 hours. It may be associated with slight vaginal bleeding or excessive mucoid vaginal discharge.

46. Cause: The exact cause is unknown. Other factors may include: Increased tension of graffian follicle just prior to rupture Peritoneal irritation by the follicular fluid following ovulation Contraction of the tubes and uterus. Treatment: Provide assurance analgesics in obstetrics cases, the cure is absolute by making the cycle anovular with contraceptive pills.

47. PELVIC CONGESTION SYNDROME There is disturbance in the autonomic nervous system which may lead to gross vascular congestion with pelvic varicosities. The patient may be congestive type of dysmenorrhoea without any demonstrable pelvic pathology.   Symptoms: Backache Pelvic pain on long standing, dyspareunia Menorrhagia or epimenorrhoea Uterus may be bulky and boggy.

48. Diagnosis: Pelvic venography Doppler scan CT/ MRI Angiography   Treatment: The treatment is unsatisfactory. Medroxy progesterone acetate (MPA) 50 mg daily for 4 months was found effective. In parous women with advancing age, hysterectomy may relieve the symptoms.  

49. ABNORMAL UTERINE BLEEDING Menorrhagia Polymenorrhoea Metrorrhagia Oligomenorrhoea Hypomenorrhoea Dysfunctional uterine bleeding

50. MENORRHAGIA Menorrhagia is defined as the cyclic bleeding at normal intervals; the bleeding is either excessive in amount (> 80ml) or duration (>7 days) or both. The term menotaxis is often used to denote prolonged bleeding.   CAUSES: Menorrhagia is a symptom of some underlying pathology- organic or functional.

51. Cause: Organic: Pelvic: Fibroid uterus Adenomosis Pelvic endometriosis IUCD in utero Chronic tubo - ovarian mass Tubercular endometriotis (early cases) Retroverted uterus – due to congestion Granulose cell tumour of the ovary.

52. Systemic: Congestive cardiac failure Severe hypertension Endocrinal: Hypothyroidism Hyperthyroidism hematological: idiopathic thrombocytopenia purpura leukemia von willebrands disease platelet deficiency emotional upset:

53. functional Due to disturbed hypothalamo - pituitary- ovarian- endometrial axis. C. Common causes: Dysfunctional uterine bleeding Fibroid uterus Adenomycosis Chronic tubo - ovarian mass

54. DIAGNOSIS: Long duration of flow. Passage of big clots Use of increased number of thick sanitary pads Pallor and low level of hemoglobin   TREATMENT: The definitive treatment is appropriate to the cause for menorrhagia .

55. POLYMENORRHOEA ( epimenorrhoea ) Polymenorrhoea is defined as cyclic bleeding where the cycle is reduced to an arbitrary limit of less than 21 days and remains constant at that frequency. If the frequent cycle is associated with excessive and or prolonged bleeding, it is called epimenorrhoea . 

56. Causes: Dysfunctional uterine. It is seen predominantly during adolescence, preceding menopause and following delivery and abortion. Hyperstimulation of the ovary by the pituitary hormones may be a responsible factor. Ovarian hyperemia- as in PID or ovarian endometritis .   Treatment: Persistent dysfunctional type is treated by hormone as in dysfunctional uterine bleeding.

57. METRORRHAGIA Metorrhagia is defined as irregular acyclic bleeding from the uterus. Amount of bleeding is variable. While metorrhagia strictly concerns uterine bleeding but in clinical practice, the bleeding from any part of the genital tract is included under the healing. The irregular bleeding in the form of contact bleeding or intermittent bleeding is an otherwise normal cycle is also indicated in metorrhagia . Menometorrgia : Is the term applied when the bleeding is so irregular and excessive that the menses cannot be identified at all.

58. Causes of acyclic bleeding: DUB- usually during adolescence following childbirth and abortion and preceding menopause. Submucosal fibroid Uterine polyp Carcinoma cervix and endometrial carcinoma . Causes of contact bleeding: Ca cervix Mucous polyp of cervix Vascular ectopy of the cervix specially during pregnancy, pill use cervix. Infections- chlamydial or tubercular cervicitis . Cervical endometritis .

59. Causes of intermenstrual bleeding contact bleeding Urethral carnucle Ovular bleeding Breakthrough bleeding in pill use IUCD in utero Decubitis ulcer   Treatment: Treatment is directed to the underlying pathology. Malignancy is to be excluded prior to any definitive treatment.

60. OLIGOMENORRHOEA Menstrual bleeding occurring more than 35 days apart and which remains constant at that frequency is called oligomenorrhoea . Causes: Age related- during adolescence and preceding menopause. Weight related- obesity Stress and exercise related Endocrine disorders- PCOS Androgen producing tumours - ovarion , adrenal Tubercular endometritis Drugs- phenothiazines , cimetidine , methyldopa

61. HYPOMENORRHOEA When the menstrual bleeding is unduly scanty and lasts for less than 2 days, it is called hypomenorrhoea . Causes: Local ( uterine synchiae or endometrial tuberculosis) Endocrinal ( use of oral contraceptives, thyroid dysfunction and premenopausal periods) Systemic (malnutrition)

62. DYSFUNCTIONAL UTERINE BLEEDING (DUB)   DUB is defined as a state of abnormal uterine bleeding without any clinically detectable organic, systemic and iatrogenic cause. (pelvic pathology eg - tumour , inflammation or pregnancy is excluded.) Currently DUB is defined as a state of abnormal uterine bleeding following anovulation due to dysfunction of hypothalamo - pituitary- ovarian axis.(endocrine origin). Heavy menstrual bleeding (HMB) is defined as a bleeding that interferes with woman’s physical, emotional, social and maternal quality of life.

63. PATHOPHYSIOLOGY The physiological mechanism of haemostasis in normal menstruation are:  Platelet adhesion formation Formation of platelet plug with fibrin to seal the bleeding vessels. Locasied vaso constriction. Regeneration of vaso constriction. Regeneration of endometrium . Biochemical mechanisms involved are: inc. endometrial ratio of PGF2 alpha/ PGE2. PGF2alpha causes vasoconstriction and reduces bleeding. Progesterone increases the level of PGF2 alpha from arachidonic acid. Levels of endothelin which is a powerful vasoconstrictor is also increased. In anovulatory DUB there is decreased synthesis of PGF2 alpha and the ratio of PGF2 alpha/ PGE2 is low.

64. The abnormal bleeding may be associated with or without ovulation and accordingly gouped into: . Ovular bleeding Anovular bleeding   Ovular bleeding includes: Polymenorrhoea / polymenorrhagia Oligomenorrhoea Functional menorrhagia   Anoovular bleeding includes: Menorrhagia Cystic glandular hyperplasia.

65. INVESTIGATION Blood investigations including T3, T4, TSH USG & color Doppler TVS Saline infusion sonography (SIS) Hysteroscopy Endometrial sampling Laproscopy Diagnostic uterine curettage (D & C)

66. COMMON CAUSE OF ABNORMAL VAGINAL BLEEDING   Organic: Uterine fibroid Endometriosis Adenomyosis Endometrial polyps IUCD Adnexal pathology

67. Hematological and endocrine: Platelet deficiency Leukemia ITP Von willebrand disease Thyroid dysfunction Non menstrual bleeding: Foreign body Urethral carnucles Genital malignancy Postcoital Intermenstrual Abortion Breakthrough bleeding

68. MEDICAL MANAGEMENT HORMONES: With the introduction of hormones , potent oral active progestins , they became the mainstay in the management of DUB in all age groups and practically replaced the isolated use of oestrogens and androgens. Eg medroxyprogesterone acetate, norethisterone acetate etc. Progestins : involves prostaglandin synthetase inhibitors (PSI) eg ; fenamates ( mefenamic acid) The preparation are used: Cyclic therapy Continuous therapy.

69. To stop bleeding and regulate the cycle : Norethisterone preparations (5mg tab ) are used thrice daily till bleeding stops which it usually does by 3-7 days. a. cyclic therapy:   5 th - 25 th day course :   In ovular bleeding ----- any low dose combined oral pills are effective when given from 5-25 th day of cycle for 3 consecutive cycles. It causes endometrial atrophy.normal menstruation is expected to resume with restoration of normally functioning pituitary ovarian endometrial axis.   In anovular bleeding --- cyclic progesterone preparation medroxyprogesterone acetate (MPA)10 MG r norethisterone 5mg is used from 5 th - 25 th day of cycle for 3 cycles.

70. 15-25 th day course: In ovular bleeding where patient wants pregnancy or in cases of irregular shedding or irregular ripening of the endometrium.dydrogesterone 1 tab (10 mg) daily bd from 15-25 th day may cure the state. It does not suppress the ovulation. Anovulatory women have immaturity of H-P-O axis. They are ideal for the use of short term cyclic therapy until the maturity of the positive feedback system is established.

71. b. Continuous progestins : Medroxyprogesterone acetate 10 mg tds daily is given and treatment is usually continued for atleast 90 days. Inj DMPA i /m can be given Oestrogen Intrauterine progestogen Danazol Mifepristone (RU 486) GnRH agonists

72. NON HORMONAL MANAGEMENT   Anti fibrinolytic agents ( tranexamic acid) Prostaglandin synthetase inhibitors NSAIDS Desmopressin SURGICAL MANAGEMENT Uterine curettage Endometrial ablation/ resection Laser Roller ball Thermal balloon Microwave novasure resection transcervical resection (TCRE)  uterine artery embolisation hysterectomy

73. COMPLICATIONS   Infections Uterine perforations (<1%) Fluid absorption may occur during hysteroscopic procedures.

74. CONCLUSION Some menstrual irregularities can be caused by serious, even life-threatening conditions, such as uterine cancer. Seek prompt medical care if you have menstrual irregularities, such as heavy menstrual periods or a lack of menstrual periods. Early diagnosis and treatment of menstrual irregularities reduces the risk of serious complications, such as infertility and metastatic uterine cancer. 

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