Topic 4-Disorders of menstrual cycle..pptx

Disorders of menstrual cycle..pptx

1. Menstrual Disorders Presented BY Chweya R.A.O. MSc . ObsGynea Nursing

2. CONTENT Overview of the Normal menstrual cycle Disorders of menstruation Infertility Disorders of implantation Abortions Tumours of the reproductive system Infections of the reproductive system

3. Overview of the normal menstrual cycle Defined as the periodic shedding of the endometrium which had been prepared for implantation. Occurs every 21-35 days (28 mean) and the duration is 1 – 8 days, day 1 being the first day of the flow. Ovulation usually occur 14 days before the next flow. Amount of blood loss ranges between 20-80 ml with an average of 50 ml. The superficial and middle layers of the endometrium are shed leaving the basal layer intact.

4. Phases of the menstrual cycle The menstrual phase occurs approximately during days 1–5 of the cycle. This phase is marked by sloughing of the functional layer and lasts through the period of menstrual bleeding. The proliferative phase follows, spanning approximately days 6–14. The initial development of the functional layer of the endometrium overlaps with the time of follicle growth and estrogen secretion.

5. One follicle grows bigger and produces more estrogen. By day 4 of menstruation ,the rising levels of estrogen cause the endometrium to start regenerating ( it thickens, the spiral arterioles grow and the glands to elongate). This period is referred to as the follicular phase of the ovarian cycle. The rising levels of estrogen begins to inhibit the secretion of FSH through a negative feedback mechanism thus the plasma levels of FSH fall. The rising levels of estrogen also trigger an increase in secretion of LH which dramatically rises 30 to 36 hours prior to ovulation termed LH surge

6. S ecretory phase , Is the last phase which occurs at approximately days 15–28. Increased progesterone secretion from the corpus luteum results in increased vascularization and development of uterine glands. If the oocyte is not fertilized, the corpus luteum degenerates, and the progesterone level drops dramatically. Without progesterone, the functional layer lining sloughs off, and the next menstrual phase begins.

7. Hormonal control of the menstrual cycle Hypothalamus secretes GnRH in a pulsatile fashion to stimulate the anterior pituitary to secrete FSH and LH (gonadotrophic hormones). Production of these hormones is regulated by the ovarian sex hormones estrogen and progesterone. On the first day of the menstrual flow, the plasma levels of estrogen, progesterone and LH are low. In response to the falling levels of estrogen, FSH levels start rising and this rising levels stimulate growth and maturation of primordialfollicles .

8. Under the stimulation of LH, the dorminant follicle raptures and releases a mature ovum into the abdominal cavity in a process of ovulation. With ovulation, the walls of the follicle collapses and the granulosa cells are converted to luteal cells and the follicle becomes a corpus luteum. Under the influence of LH these cells continue to produce both estrogen and progesterone but the predominant hormone produced is progesterone. This phase is called the luteal phase. Plasma levels of estrogen and progesterone continue to rise after ovulation and peaks between third to fourth day and is maintained upto day 11 following ovulation.

9. The increasing amount of estrogen and progesterone suppresses secretion of LH and FSH. If fertilization does not occur, the corpus luteum degenerates and becomes corpus albicans. It can no longer produce the sex hormones. The fall in plasma levels of progesterone causes endometrial withdrawal bleed and premenstrual rise in FSH levels which signals the beginning of a new cycle. Prior to menstruation, the endometrium undergoes ischemia and is sloughed off.

10. Menstrual Disorders Introduction : Menstrual disorders are very common in young girls, and can be the cause of a significant amount of stress and anxiety to both the patients and their parents. The term menstrual disorder refer to any conditions or irregularities that are related to the woman's menstrual cycle The common menstrual disorders in adolescents are amenorrhea, abnormal/excessive uterine bleeding, dysmenorrhea, and premenstrual syndrome.

11. Factors that may affect the menstrual cycle: Breast-feeding. Rapid weight change - increase or decrease. Body weight below a certain level eg, in eating disorders, particularly anorexia nervosa. Emotional stress. Significant Illness. Medication

12. Amenorrhea This refers to the absence of menstruation This can be classified as primary or secondary amenorrhea. Primary a menorrhea: Absence of menses after the age of 16 years in the presence of secondary sexual characteristics or the absence of menses after the age of 14 years in the absence of secondary sexual characters. Secondary amenorrhea : Stopping of menstruation after it was regular before for at least 3 consecutive cycles.

13. Physiological amenorrhea This occurs: before puberty, during pregnancy, lactation and at menopause. Before puberty: - Lower gonadotrophins with low estrogen and progesterone Pregnancy: - Continuous estrogen and progesterone production without withdrawal. Lactation: - High prolactin production resulting in ovarian suppression. Menopause: - Exhaustion of the ovarian follicles with low estrogen and progesterone.

14. Pathological amenorrhea False amenorrhea (crypto menorrhea): Menstruation occurs every month but the blood flow is prevented due to an out flow tract obstruction. The blood is retained inside the vagina resulting in hematocolpos, inside the uterus resulting in hematometria , or in the fallopian tube resulting in hematosalpinx .  The accumulated blood forms a pelvic -abdominal mass and becomes decomposed changing into dark chocolate like fluid. Causes include: Cervical atresia , Vaginal atresia , Transverse vaginal septum and Imperforate hymen which is considered as the most common cause. 

15. Clinical picture:   Symptoms: Occur after the age of puberty., patient presents with primary amenorrhea accompanied with Recurrent cyclic colicky lower abdominal pain. Abdominal mass (mistaken for pregnancy) with pressure symptoms particularly on the urethra resulting in acute urine retention. General examination: reveals well developed secondary sexual characteristics. Abdominal examination: reveals central cystic pelvic abdominal mass which is dull on percussion. In presence of imperforated hymen, bluish colored distended complete hymen is seen on speculum exam and the bulging increases with cough. In presence of transverse vaginal septum, the hymen is normal with the site of the obstruction above the level of the hymen. In presence of cervical atresia (only hematometria is present): the vagina and hymen may be normal. 

16. Investigations:   Ultrasonography can show hematocolpos and hematometria if present. Intravenous pyelography : to detect associated urinary abnormalities (in kidney). Treatment :  Imperforated hymen: partial hymenectomy is done by cruciate incision of hymen and trimming followed by marsupialization of its edges( Marsupialization  is the surgical technique of cutting a slit into   cyst  and suturing the edges of the slit to form a continuous surface from the exterior surface to the interior surface of the cyst). The retained blood is left to be drained spontaneously. Transverse vaginal septum is treated by incision.

17. True amenorrhea For normal menstruation to occur the following are required: Essential factors: Normal pituitary gland function which is dependent upon (gonadotrophic releasing hormones) from the hypothalamus. Normal ovarian function which depends upon gonadotrophic hormones from pituitary gland. Intact uterine target organ with healthy endometrium responsive to ovarian hormones. Intact outflow tract. Auxiliary factors: General condition. Nervous status. Body weight changes. Normal thyroid gland function.

18. Etiology of true amenorrhea Aplasia ( mullerian agenesis)- congenital malformation characterized by absence of uterus and vagina Severe uterine hypoplasia Ashermans ’ syndrome Inflammatory conditions of the endometrium Surgical removal of the uterus or ovaries. Ovarian hypo function due to premature ovarian failure Ovarian tumours Polycystic ovarian syndrome Following irradiation of ovaries

19. Pituitary tumours Simmonds disease Sheehan’s syndrome Conditions affecting hypothalamic functions Functional causes like anorexia nervosa, bulimia, athletic amenorrhea, psychological upset. Drugs like injectable contraceptives, oral contraceptives, electro convulsive therapy, GnRH agonists, medications that raise serum prolactin.

20. Treatment The treatment of primary amenorrhea involves the correction of any underlying disorders and estrogen replacement therapy to stimulate the development of secondary sexual characteristics. Therapeutic interventions for secondary amenorrhea may include: Cyclic progesterone when the cause is an ovulation, or oral contraceptives. Bromocriptine to treat Hyperprolactinemia . Nutritional counseling to address anorexia, bulimia, or obesity. Gonadotrophin releasing hormone ( GnRH ), when the cause is hypothalamus failure. Thyroid hormone replacement. When the cause is hypothyroidism.

21. Nursing management History taking Physical examination Laboratory and radiological assessment Psychological and emotional support Reduce stress and emotional upsets. Health teaching about: Proper balanced diet. Correction of body weight. A moderate exercise program may restore normal menstruation. Finding ways to deal with stress and conflicts may help. Maintaining a healthy lifestyle The follow-up is performed to monitor ovarian hormonal replacement.

22. DYSMENORRHOEA Painful menstruation that incapacitate the women and may render them unable to perform their work, keep one in bed or force her to ask for medical advice. Types: Primary ( Spasmodic Dysmenorrhea) Secondary ( Congestive dysmenorrhea )

23. Primary ( Spasmodic Dysmenorrhea) Primary, uterine, essential, intrinsic, or colicky dysmenorrhea refer to menstrual pain without organic pelvic pathology. Rarely starts at menarche; it usually starts 2 to 4 years after menarche reaching its’ worst between 18 to 20 years of age. Sexual debut and pregnancy cure dysmenorrhea in a good number of women. Child bearing cures dysmenorrhea in some women because labor brings about dilatation of the cervix

24. Clinical presentation: Pain is Colicky in nature, comes in waves and is followed by dull ache. It recurs every 5-30 min for a duration of 0.5-1 min. The pain is felt at the suprapubic region and may radiate to back and anterior aspect of the thighs. Starts with the onset of menstrual flow and may last for 1 or 2 days. Functional disturbance of intestinal tract: nausea and vomiting. Autonomic system imbalance: pallor and sweating may be observed. Causes of spasmodic dysmenorrhea: Is uterine in origin, the main pathogenesis is hyper contractility of the myometrium which decreases the uterine blood flow which causes uterine ischemia with angina like pain.

25. Treatment of spasmodic dysmenorrhea:   Preventive measures: Psychological support. Correction of over or under weight Elimination of stress Exercise General measures: Bed rest during the menstruation. Hot water bottle application on the lower abdomen. Medical treatment: Analgesics and antispasmodics Prostaglandins synthetase inhibitors such as aspirin, ibuprofen (NSAID) Hormonal treatment COCs pills that inhibit ovulation and corpus luteum formation. Estrogen is useful in cases of hypoplasia .

26. Congestive dysmenorrhea (Secondary) - Appears later or at the time of menarche but more prevalent between 30-40 years. Pain starts several days before menstruation, usually 2-3 days before menses and is relieved by the onset of the flow. Constant dull ache or heaviness felt in the lower abdomen. Associated with nausea & vomiting, headache & general malaise.

27. Causes Pain is due to increased pelvic congestion which results from: Functional causes: pelvic congestion syndrome. Organic causes: Inflammatory:(Chronic cervicitis and Chronic PID) Uterine displacement. Varicose vein in broad ligaments Neoplastic (Ovarian tumors ) Endometriosis (uterine or extrauterine).  

28. Treatment of congestive dysmenorrhea: Treatment of the underlying organic cause. Measures to decrease pelvic congestion. Avoid constipation. Hot vaginal douches. Analgesics and anti-inflammatory drugs are also helpful. Possible nursing diagnosis for dysmenorrhea: - Acute pain related to increased uterine contractility, hypersensitivity  -Ineffective individual coping related to emotional excess .

29. PREMENSTRUAL SYNDROME Premenstrual syndrome is the occurrence of cyclical somatic and psychological symptoms during the luteal phase of menstrual cycle and resolve by the time menstruation ceases. Causes is unknown, however, possible causes may be: Progesterone may lead to decrease of GABA which may inhibit brain serotonin levels.

30. Clinical presentation Physical Backache Bloating Breast fullness and pain Changes in appetite and cravings for certain foods Constipation Fatigue Cyclic weight gain, edema. Abdominal cramps Headache Psychological Anxiety Confusion Crying spells Depression Difficulty concentrating Irritability Mood swings Nervousness

31. Treatment of PMS: Diuretics may be helpful in treatment of bloating and breast tenderness. Combined Oral contraceptive pills to inhibit ovulation. Use of non-steroidal anti-inflammatory drugs (NSAIDs) as aspirin.

32. Nursing role Prevention of primary dysmenorrhea through health education about physiology of menstruation, carrying normal activities, participating exercises (Increase endorphin level which improve mood), taking bath, relieving constipation, correcting underweight, overweight & anemia Complete history, examination & investigation. Health teaching about how to reduce pain by using hot water bottle & waist exercise to divert attention. Health teaching about hygienic care. Salt free diet one week before menstruation in case of premenstrual tension. Psychological support through reassurance & advice.

33. HYPOMENORRHEA Refers to a decrease in the amount of menstrual flow while the periods are regular in rhythm, the deficiency is either in the amount of blood lost or in the duration which is less than two days. Causes: General factors e.g. anemia and chronic nephritis Hypothyroidism Uterine hypoplasia Partial asherman's syndrome When one ovary is removed. The flow becomes less for sometimes after the operation. Until the remaining ovary makes up for the loss. Treatment Depends on the cause: Improve the general condition Cyclic therapy by estrogen and progesterone gives the best results in most cases.

34. OLIGOMENORRHEA This means normal periods at longer intervals i.e. the menstrual cycle is prolonged " oligo " in Greek means few, so the patient gets a fewer number of cycles per year, or Infrequent menstruation (length of the cycle is more than 35 days). Causes: O varian dysfunction Commonly present after menarche and before menopause. Obese patients are liable to have ovarian sub function resulting in infrequent ovulation and Oligomenorrhea Oligomenorrhea is prominent symptom in many cases of polycystic ovaries and Sheehan's syndromes. Treatment Treatment is carried according to cause. Cyclic estrogen then progesterone therapy gives permanent cure. Oral contraceptives give regular period during therapy.

35. POLYMENORRHEA Refers short menstrual cycles or too frequent menstruation at regular intervals of 2 weeks but less than 3 weeks, with more periods per year. The bleeding may not be excessive. Causes:   Occurs after puberty & before menopause because of premature degeneration of corpus luteum. Ovarian congestion related to RVF, uterine prolapse, fibroid uterus, chronic salpingo-oophritis . Hormonal dyscrasias e.g. hypothyroidism which lead to premature degeneration of corpus luteum. Management: same as Oligomenorrhea .

36. MENORRHAGIA Is an excessive regular menstrual loss (>80 ml) of normal duration. Causes: General Early hypo and hyperthyroidism Blood diseases Acute infectious fevers Congestive heart failure Fatigue and chronic constipation Hypertension Change to a hot climate Local causes Increased area of endometrium e.g. fibromata and sub involution Thickened (hyper plastic) endometrium Interference with venous return from the uterus e.g. ovarian tumor, RVF, uterine prolapse. IUD Treatment depend on the cause

37. METRORRHAGIA Irregular or unusual bleeding (bleeding at times other than those when period is expected). Bleeding may range from slight spotting to hemorrhagic flow & from a single short period to bleeding that continues for days. It is a common symptom of: Uterine malignancy especially endometrial carcinoma. Cervical erosions & polyps.

38. Causes: Trauma e.g. contraceptive device, uterine inversion Infection e.g. senile endometritis and vaginitis Threatened abortion, Ectopic pregnancy, vesicular mole. Cancer & benign tumors of the uterus. Chronic nephritis. A special type of Metrorrhagia is post coital bleeding. Treatment: Treat the cause Estrogen therapy.

39. MENOSTAXIS Regular period with normal flow but prolonged duration. Causes : Irregular response of endometrium to ovarian hormones, which lead to irregular patchy necrosis of the endometrium [an area is menstruating & other area is in premenstrual period (irregular ripening)]. Dysfunctional due to : Pituitary or ovarian dysfunction leading to irregular supply of sex hormones. Endometrial dysfunction leading to irregular response to normal supply of hormone. Organic: irregular preparation of the endometrium for menstruation e.g. sub-mucous fibroid, endometrial polyp, uterine displacement, peri-uterine adhesion, which interfere with proper uterine contraction that normally stops period.

40. Management: Organic causes should be treated by correction of the abnormality. Irregular ripening is treated by progesterone therapy. Thyroid therapy is useful to activate the corpus luteum. Estrogen therapy & curettage are used to treat irregular shedding.

41. METROPATHICA HEMORRHAGICA Period of amenorrhea followed by prolonged heavy & irregular bleeding of such severity that it may occasionally be life threatening. This condition most commonly occurs around the time of the menopause but may occur before. Causes : The persistence of an un-ruptured graffian follicle, which exists in one-ovary & results in extended & excessive estrogen production that causes cystic ovaries or adenomatous endometrial hyperplasia. N.B . hemorrhage commonly follows a period of 6-8 weeks amenorrhea. Treatment: Stimulation of corpus luteum by progesterone injection. Pituitary gland suppression by using oral contraceptive pills. Radiological therapy may be administrated to patients near menopause. Surgical therapy by curettage, hysterectomy may be done.

42. ABNORMAL UTERINE BLEEDING This term describes the occurrence of abnormal uterine bleeding for which organic causes cannot be found. Abnormalities of the uterine bleeding most commonly occur at the extremes of menstrual life & particularly in the premenopausal years. These conditions are classified as ovular or anovular . Management:   High dose of progesterone. Curettage. Endometrial resection. Hysterectomy .