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1. Division of Reproductive Health
MENSTRUAL DISORDERS
Prepared By
Samina Roohi
Senior Nursing Instructor
Aziz Fatima CON
Faisalabad

2. Division of Reproductive Health
Specific Objectives
•By the end of this session the Learner will be
able to:
–Define Normal menstruation
–Classify Menstrual Disorders
–Explain characteristics of the different menstrual
disorders
–Demonstrate ability to diagnose menstrual
disorders
–Apply Knowledge and skills acquired to manage
menstrual disorders.

3. Division of Reproductive Health
Definition of normal menstruation
•It is the cyclical shading of a functional
endometrium; and has the following
characteristics:
•Amount of flow: 25-80 ml average 30 mls
•Cycle length: 21-35 days
•Duration of flow: 2-7 days
•Healthy menstrual blood does NOT coagulate
•It occurs in a cyclic manner and regularly

4. Division of Reproductive Health
Classification of menstrual disorders
•Premenstrual syndrome (PMS)
•Mastodynia
•Abnormal bleeding due to gynecologic and non
gynecologic disorders:
–Amenorrhea, oligomenorhea, hypomenorrhea,
menorrhagia, polymenorrhea, metrorrhagia, etc
•Dysmenorrhoea
•Dysfunctional uterine bleeding (DUB)
•Post menopausal bleeding

5. Division of Reproductive Health
Characteristics of Menstrual
disorders

6. Division of Reproductive Health
Premenstrual syndrome:
•occurs in at least 3 consecutive menstrual cycles
•Symptoms must occur in the 2
nd
half of the
menstrual cycle (luteal phase)
•There must be a symptom free period of at least
7 days in the 1
st
half of the cycle
•Symptoms must be severe enough to require
medical advise or treatment e.g. oedema, weight
gain, restlessness, irritability and increased
tension.

7. Division of Reproductive Health
Premenstrual syndrome cont’d:
Symptoms include:
•Mood symptoms ( irritability, mood swings,
depression, anxiety)
•Physical symptoms ( bloating, breast
tenderness, insomnia, fatigue, hot flushes,
appetite change, e.t.c)
•Cognitive changes (confusion and poor
concentration)

8. Division of Reproductive Health
PMS -Diagnosis
•Mainly based on patient’s history
•Patient charts symptoms for at least 3
symptomatic cycles
•Rule out medical conditions that mimic PMS
e.g. thyroid disease and anemia.

9. Division of Reproductive Health
PMS- Management
( Conservative)
•Diet: (limit caffeine, alcohol, tobacco and
chocolate intake; eat small frequent meals
•Decrease sodium intake
•Stress management;
•Aerobic exercises
•Cognitive behavioral therapy

10. Division of Reproductive Health
PMS management
(Drug therapy)
•Calcium carbonate (for bloating, pain and food
cravings)
•Magnesium ( for water retention)
•Vitamin B6 and vitamin E
•NSAIDs
•Bromocryptine for mastalgia

11. Division of Reproductive Health
Mastodynia
•Also termed mastalgia
•Defined as: intolerable breast pain during the
second half of the menstrual cycle.
• caused by edema and engorgement of the
vascular and ductal systems
•Occurs cyclically in the luteal phase

12. Division of Reproductive Health
Mastodynia -diagnosis
•History and examination
•Can be confirmed by aspiration
•Ultrasound
•Serial mammography
•Excisional biopsy sometimes is necessary
•Rule out: Mastitis, neoplasm

13. Division of Reproductive Health
Mastodynia- treatment
•Breast support
•Avoid- coffee, tea, chocolate, cola drinks
•Avoid nicotine
•May occasionally use a mild diuretic
•Drug therapy: topical NSAIDS, Gosarelin
(Zoladex),
•Limited success with: tamoxifen, danazol,
bromocryptine, oral contraceptives, vitamins

14. Division of Reproductive Health
Menorrhagia (Hypermenorrhea)
•Defined as excessive, heavy or prolonged
menstrual flow
•Possible causes include: submucous myomas,
adenomyosis, IUDs, endometrial hyperplasia,
malignant tumors e.t.c

15. Division of Reproductive Health
Hypomenorrhea (cryptomenorrhea)
•Defined as unusually light menstrual flow
sometimes only spotting
•Possible causes include: hymenal or cervical
stenosis, uterine synechiae (Asherman’s
syndrome), occasionally oral contraceptives

16. Division of Reproductive Health
Metrorrhagia (intermenstrual bleeding)
•Defined as bleeding occurring any time
between the menstrual periods
•Possible causes include: endometrial polyps,
CA cervix, CA endometrium, exogenous
estrogen administration

17. Division of Reproductive Health
Polymenorrhea
•Describes periods that occur too frequently
•Usually associated with anovulation and rarely
with a shortened luteal phase in the menstrual
cycle

18. Division of Reproductive Health
Menometrorhagia
•This is bleeding that occurs at irregular
intervals and varies in amount and duration of
bleeding
•Caused by any condition that can lead to
intermenstrual bleeding

19. Division of Reproductive Health
Oligomenorrhea
•Describes menstrual periods that occur more
than 35 days apart
•Possible causes: anovulation which may be
from endocrine causes (pregnancy,
menopause, pituitary and hypothalamic
disorders); or systemic causes (excessive
weight loss); estrogen secreting tumors etc

20. Division of Reproductive Health
AMENORRHEA
•No menstrual period for more than 6 months
•Possible causes:
-Congenital uterine absence
-Hormonal disturbances from the hypothalamus
and pituitary gland
-Failure of the ovary to receive or maintain egg
cells
-Genetic diseases e.g. causes of intersex i.e. 5-
alpha-reductase deficiency

21. Division of Reproductive Health
Diagnosis in abnormal uterine bleeding
•History and physical examination
•Cytological examination –include biopsy and
histology
•Pelvic ultrasound scan
•Endometrial biopsy
•Hysteroscopy
•Dilatation and curettage
•Hormonal profile
•Blood tests- Haemogram, thyroid function tests e.t.c.

22. Division of Reproductive Health
Management of abnormal uterine
bleeding- principles
•Treat cause appropriately
May include
•Hormonal preparations
•Surgery
•Endometrial ablation and endometrial
resection, Prostaglandin synthetase inhibitors,
•Levonogestrel releasing IUDs

23. Division of Reproductive Health
Dysmenorrhea
•Definition: Pain associated with menstruation
•Risk factors:
–Menstrual factors (early menarche, menorrhagia)
–Parity (lower in multipara)
–Diet (reduced intake of fish, eggs and fruits)
–Exercise (reduces dysmenorrhoea)
–Cigarette smoking (increases)
–Psychological (emotionally dependent and overprotected
girls, family history,)

24. Division of Reproductive Health
Dysmenorrhea- classification
•Primary or spasmodic dysmenorrhea:
–Essential/ intrinsic / functional. Defined as painful
menstruation in absence of pelvic pathology
–Usually starts at puberty
–Follows onset of ovulation and presents throughout period
of bleeding.
•Congestive or secondary dysmenorrhea:
–Underlying pelvic disease e.g. uterine abnormalities,
infections, endometriosis, foreign bodies, iatrogenic
•Membranous dysmenorrhea:
–associated with passage of endometrial cast through an
undilated cervix.

25. Division of Reproductive Health
Dysmenorhea- clinical features
•Primary Dysmenorhea:
–Age: Usually seen among younger women
–Time of onset: 2-3 yrs after menarche
–Duration of pain: starts just prior to menses, lasts
about 2 days
–Type of pain: cramping pain
•Membranous Dysmenorhea:
–Intense cramping pain associated with passage of
an endometrial cast through an undilated cervix.

26. Division of Reproductive Health
Dysmenorhea- clinical features (ctd)
•Secondary Dysmenorhea:
- Associated with specific diseases and disorders e.g.
PID, Uterine fibroids, endometriosis etc
–Usually among older women (3
rd
to 4
th
decade)
–Time of onset: follows initial years of normal
painless cycles
–Duration of pain: Onset is few days prior to menses
and continues throughout cycle even after cessation
of menses
–Type of pain: continuous dull aching or dragging
pain

27. Division of Reproductive Health
Dysmenorhea -management
Dysmenorhea
Assurance
Laxatives
Analgesics and Antispasmodics
Fails
Contraception not required or OC pills
contraindicated
Contraception required or NSAIDS contra
indicated
Prostaglandin synthetase inhibitors OC pills
Fails
Laparoscopy to look for causes of secondary Dysmenorhea
No cause found but persistent and
severe pain
Cause found
Surgery
Treat as appropriate

28. Division of Reproductive Health
Dysfunctional Uterine bleeding
(DUB)
•Defined as a symptom complex that includes
any condition of abnormal uterine bleeding in
the absence of pathologic cause
•Commonly caused by anovulation as seen in
polycystic ovarian disease and obesity
•May occur in all age groups from prepubertal
girls to menopausal women

29. Division of Reproductive Health
DUB management
•Medical management:
–NSAIDS
–Antifibrinolytic agents
–Hormones
•Surgical
–Endometrial resection
–Endometrial ablation
–hysterectomy

30. Division of Reproductive Health
Postmenopausal bleeding
•Any vaginal bleeding in a postmenopausal
women should be considered abnormal
•Frequently associated with malignancies of the
reproductive tract
•Benign causes include: endometrial /cervical
polyps, trauma, senile vaginitis, vulval
dystrophies
•Management depends on the cause.

31. Division of Reproductive Health
Thank You