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Menstrual disorders......

 

Menstrual disorders

 

INTRODUCTION

AGE OF ONSET 

LENGTH OF MENSTRUAL CYCLE

AVERAGE BLOOD LOSS 

SOME COMMON MENSTRUAL DISORDERS

Dysmenorrhea

Clinical features

Causes

Treatment

 Dysfunctional uterine bleeding (DUB)

Incidence

Causes of abnormal vaginal bleeding

Classification

Treatment of DUB 

Amenorrhea

Causes of Amenorrhea

Aneroxia Nervosa

 Menorrhagia

Causes of menorrhagia

Is menorrhagia dangerous?

What you should know in relation to menstrual pain

 Premenstrual syndrome or PMS

Physiological premenstrual change

Primary PMS

Clinical features

Treatment 

Psychotherapy

Exercise

Hormonal therapy

 

Introduction

 

Menstruation is a function peculiar to women and higher apes. It describes the periodic loss of blood from the female genital tract in the normally sexually mature human female resulting from the regular shedding of the endometrium. The normal menstrual function depends upon

Intact patent outflow.

Ovarian function, which is normal

Normally functioning pituitary

Absence of hypothalamic disorders

There is a pulsatile release of GnRH (growth reproductive hormone) from the hypothalamus, which brings about the release of hormones from the pituitary and ovaries to ultimately cause menstruation

Age of onset

The onset of menstruation or menarche occurs at an average age of13 years but with improving nutrition and general health of the population it may occur much earlier. The initial menstrual cycles are often characterised by irregularity of both rhythm and flow with an associated mistaken belief of associated infertility during this period.

Length of menstrual cycle

This varies considerably between individuals and in the same individual. It is generally assumed that menstrual cycles vary from 21 to 40 days whilst bleeding periods from 3 to 7 days duration fall within normal limits. The average length of the menstrual cycle is 26 to 30 days.

What is the average blood loss?

The average blood loss during a normal period is approximately 60 ml and may vary physiologically from 30 to 180 ml. The blood loss is so subjective that the haemoglobin value should be monitored for an objective assessment of loss. Half of the menstrual discharge is blood and the remainder consists of mucus, fragmented endometrial tissue and desquamated vaginal epithelium. Menstrual blood does not usually clot and the presence of clots is often an indication of excessive menstrual loss. The endometrium is thought to produce a lytic agent that rapidly disintegrates the clots.

Some Common menstrual disorders

There are many different types of menstrual disorders with causes and treatment. The common ones are:

Dysmenorrhea – Excessive menstrual cramps. This is a painful menstruation of sufficient magnitude so as to incapacitate the woman in her day to day activities. It is the commonest of all gynecological complaints. Approximately 50% women feel some pain during menstruation, most often mild abdominal or back aches. But in some cases, cramps that come as uterus contracts to shed its lining may hurt so much that one is unable to work and may have to stay in the bed. Painful periods from time to time are one thing; but if it interferes with one’s daily life for more than two months then it may be a cause of concern. Sometimes even experts can’t explain the pain.

 

Clinical features

Usually adolescent girls within 2 years of menarche, more or so in sophisticated society, experience it. It has family tendencies. The pain begins with the onset of menstruation and lasts for 12 to 72 hours. It is usually confined to the lower abdomen in the midline, the character of pain being crampy and of intermittent intensity. It may radiate to the back and thighs.

The abdominal pain is associated with nausea, diarrhea, fatigue, headache and a general sense of malaise. The severity decreases after the first day.

 

Causes

Many theories have been put forward-

Psychosomatic factor: two types of personalities are prone to dysmenorrhea, i.e. tomboyish immature shy and self-conscious type.

Abnormal anatomical and functional aspect of the uterus: the pain is due to unequal muscular contraction and inappropriate polarity of the uterus whereby the cervix does not dilate with uterine contractions.

Hormonal imbalance theory: this is based on the fact and observation that only the ovular menstruation is painful

 

Treatment

The treatment should be started

Based on the fact that PGs play a role in dysmenorrhea the logical treatment is with prostaglandin inhibitors. They help in inhibiting the enzyme cycloxygenase, which is responsible for the production of PGs

Oral contraceptive pills. They help in minimizing the anovulatory cycles and suppress the production of endogenous progesterone. These are given for 3-6 cycles.

General measures like improving the health status, alleviation of fluid retention by low sodium diet and psychotherapy should be provided

Surgical management is the last resort.

 

Dysfunctional uterine haemorrhage: Abnormal uterine haemorrhage is a common clinical problem and various terms are used to describe common menstrual disorders. In general period may be too heavy, too long or too frequent and the term dysfunctional uterine haemorrhage is used, after the exclusion of organic disease including tumours, to imply hormonal imbalance. Whilst research has shown hyperoestrogenic disorders or an excess of local prostaglandin to produce such hormone imbalance, it is normal to proceed to an examination under anaesthesia; also a diagnostic fractional curettage of the uterus (D &C), and where indicated a laparoscopic assessment of the pelvis including ovaries..

 

Incidence

Contrary to the belief that DUB occurs only at extremes of reproductive life, it is seen that 50% cases occur at 20 to 25 years of age, 11% occurs in <20 years and 39% occur in > 40 years of population.

 

Causes of abnormal vaginal bleeding

Pregnancy

Abortion- threatened/incomplete.

Ectopic pregnancy is the implantation of developing embryo outside endometrial cavity.

Anovulation

Endonmetrial hyperplasia

Benign uterine diseases- Adenomyosis, endometrial polyp.

Coagulopathy

 

Treatment

This is mainly in the form of hormonal therapy

Estrogens: they are used to arrest haemorrhage in severe DUB as an emergency measure, by promoting regeneration of the endometrium.

Progesterone: To arrest haemorrhage. It is very effective within 24 to 48 hours  

 

Amenorrhoea

Absence of periods. These are two types- primary and secondary.

Primary is defined as the absence of menstruation by the age of 14 years in the absence of growth or development of secondary sexual characteristics or no menses by the age of 16 years regardless of normal growth and development with appearance of secondary sexual characteristics.

Secondary amenorrhoea is defined as absence of menses for a length of time equivalent to three previous cycle interval or 6 months

Periods stop when you are pregnant, under stress, or have an illness such as anorexia that slows down body functions, including the menstrual cycle. You can sometimes prevent menstrual disorders by changing your diet, easing stress, and exercising. If you have a mild menstrual disorder, over-the-counter drugs and home remedies can help.

 

Causes of Amenorrhoea

It can be considered under following categories:

Outflow tract abnormalities

Ovarian causes

Pituitary causes

Hypothalamic cause

 

Outflow tract abnormalities

A few causes of this are imperforate (hole) hymen, transverse vaginal septum. The treatment is surgical removal

 

Ovarian causes

30 to 40% percent are due to gonadal causes. The conditions are premature ovarian failure due to irradiation.

The treatment is to stimulate ovulation with medicine, hormone replacement therapy,

and oocyte donation.

 

Pituitary causes

The common causes are-

Pituitary tumors

Sheehan syndrome

The treatment can be medical, surgical, or radiotherapy, but the most common is medical.

 

Hypothalamic causes

There are number of hypothalamic causes but a special example of hypothalamic amenorrhoea is anorexia nervosa.

 

Anorexia Nervosa

The diagnosis is done by the following:

Onset between 10 to 30 years.

Weight loss of 25% or weight 15% below normal for age and height.

Dismal distorted body image and unusual hoarding

At least one of the following- lanugo, overactivity, episodes of overeating, vomiting.

Amenorrhoea.

No medical illness

Constipation, low BP, diabetes insipidus

The probable cause may be to meet social norm of thinness, and taking normal puberty growth as abnormal.

The condition can be treated by psychotherapy, weight gain and HRTs

Menorrhagia-(heavy menstruation): With this disorder, the cycle interval (generally 27-32 days) is consistent from cycle to cycle.  Women experiencing menorrhagia often complain of frequent pad changes (more than every two hours), nocturrhagia (see below), passage of large clots, or severe     cramps. Menorrhagia is the single most common menstrual disorder that we evaluate and treat.  It is often associated with hypermenorrhea.

Hypermenorrhea—menstruation that lasts longer than 7 days

Nocturrhagia—menstruation that interferes with a woman’s sleep pattern by forcing her to change pads or tampons in the middle of the night.

Polymenorrhea—a disorder in which cycles are shorter than 25 days.

Oligomenorrhea—a change in menstrual flow characterized by light periods or spotting.

Metorrhagia—spotting between periods.  Women with this disorder generally have regular cycles with a predictable number of days of bleeding.  However, they may experience spotting during any portion of the cycle.

Causes of menorrhagia

There are many causes of increasingly heavy periods. They fall into main four categories-

Coagulation disorder.

Dysfunctional uterine bleeding (DUB)

Pelvic pathology.

Medical disorder.


Coagulation disorder

This have a variable effect overall. There is no impairment of systemic coagulation in those with excess menstrual loss, nor are fibrin degradation products elevated in menstrual fluid of those with excess menstrual loss.

 

Menorrhagia in the presence of pathology (Pelvic Pathology)

This is thought to be associated with uterine tumour, polyps, pelvic infection and presence of other foreign body such as intrauterine contraceptive device.

 

Medical disorder

Menorrhagia is associated with various endocrine disorders such as hypothyroidism and Cushing’s disease.

 

Is menorrhagia dangerous?

In the vast majority of cases, menorrhagia is not dangerous, but represents a serious inconvenience for women that are affected.  In about 1% of women with menorrhagia, an underlying cancer is the cause of their heavy menstrual flow.   Women over the age of 35 with progressively heavier menstrual flows should be tested so that an underlying cancer can be ruled out as the cause of their heavy menstrual periods.

 

What you should know in relation to menstrual pain

Consult a gynaecologist to undergo a complete examination.

Menstrual pains more frequent in obese, anxious, spasmophilic, or nervous persons. This is also true for women with irregular cycles or blood circulation problems.

Avoid taking analgesics without medical prescription, because some are dangerous and others, such as aspirin, increase bleeding. You should be aware of the fact that, in no way can they help cures condition.

Be careful not to traumatize the young girls with whom you may be in contact, by constantly complaining about your own menstrual pains. Instead, make sure they are properly informed, educated, and adequately prepared by learning all about the menstrual cycle before puberty.

Premenstrual syndrome or PMS

 

This was first documented by Frank who suspected that the disorder was related to estrogen excess. This problem is considered as disorder of middle-class educated women, may be because they can report their symptoms well.  It is a term for the many symptoms more than 150 women can get during the two weeks leading up to their periods. About 75% of females have premenstrual syndrome, which may range from mild to severe. It is estimated that 30% of females have symptoms so serious that they cannot perform daily activities. About 7% have a form so disabling that it has its own psychiatric name-premenstrual dysphoric disorder.


Physiological premenstrual change

All except 5% women experience at least one premenstrual symptom. In most of the cases it is tolerated and it does not interfere with normal function.  When it starts interfering then it is PMS.  This can be primary or secondary depending upon the degree of underlying psychopathology.


Primary PMS

It is a non-specific somatic, psychological or behavioural symptoms occurring in premenstrual phase of the menstrual cycle. They resolve completely by the end of menstruation.  The symptoms may produce social, family or occupational disruption. Symptoms have at least occurred four of the six previous menstrual cycles.

There is a group of women who have continuous or non- cyclical psychological problems wrongly attributed to PMS. This group needs appropriate treatment.

 

Clinical features

The marked features are- depressed mood, marked anxiety, marked affective labiality, and decreased interest in activities. Five or more of the following symptoms must have been present most of the time during the last week of the luteal phase, with at least one of the symptoms being one of the four:

Feeling sad, hopeless, or self-deprecating

Feeling tense, anxious or on the edge.

Marked labiality of the mood interspersed with frequent tearfulness.

Persistent irritability, anger and increased interpersonal conflicts

Decreased interest in usual activities, which may be associated with withdrawal from social relationships,

Difficulty in concentration

Feeling fatigued, lethargic, or lacking in energy

Marked changes in appetite, which may be associated with binge eating or craving certain foods.

Hypersomnia or insomnia

A subjective feeling of being overwhelmed or out of control

Physical symptoms such as breast tenderness or swelling, headaches, or sensations, or weight gain. The symptoms may be accompanied by suicidal thoughts.

 

This pattern of symptoms must have occurred for the previous 12 months. The symptoms disappear completely, shortly after the onset of menstruation. Atypically, some females also have symptoms for few days around ovulation; a few females with short cycles might, therefore, be symptom free for only 1 week per cycle.


Criteria necessary to diagnose PMS

Symptoms must occur specifically in the premenstrual phase of the cycle.

Symptoms must disappear (primary PMS) or improve (secondary PMS) during menstruation.

The character of symptoms need not be specific.

Symptoms should be of sufficient severity to disrupt the patient’s life.

Symptoms should have been present in at least four of the previous six cycles.

 

Treatment

This depends on the establishment of the correct diagnosis. This should be aimed at detecting and treating any underlying psychopathology, increasing the patient’s threshold for symptoms, and altering her hormonal status.

 

Psychotherapy

For the treatment of PMS has been very effective. Several authors have described the benefit of supportive therapy; have offered women a forum for understanding the disorder and for understanding that they are not alone. Some of the useful approaches are support to make life-style adjustments, to cope with symptoms and relationship issues, and learning to assert, handle stress, and improve time management and self-esteem.

Exercise

Regular exercise has been associated with decreased breast tenderness, fluid retention and stress complaints, but not necessarily with improvements in anxiety or depression. Several groups have examined vitamin and mineral supplementation as a treatment for PMS. Vit. A and Vit. E have been suggested as treatments for PMS.

 

Hormonal therapy

Oral contraceptive pill- there are no good therapeutic studies of the current lower estrogen dose preparations nor of the progestogen-only pills. In majority of studies, women who have already been taking higher dose combined pills have been compared with non-pill users.

 

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