Menstruation and Vaginal Bleeding

Dr. Miada Mahmoud Rady

EMS/473

Gynecological emergencies lecture 2

Menstrual cycles

Menstruation: the cyclic and periodic discharge of 25 to 65

mL of blood, epithelial cells, mucus, and endometrial tissue

that normally lasts from 2-7 days and recurs every 21-35days

(28+/-7 days).

So the average duration of menstrual blood flow is 2-7 days.

Menstruation normally occur every 21- 35 days.

Menarche: the onset of first menstruation and it typically

occur between 11- 14 years of age.

Systemic Changes During Menstrual Cycle

1. Weight gain due to salt and water retention.

2. Increased muscle tonicity and susceptibility to bruising.

3. Breast pain and tenderness resulting from swelling

4. Headache including menstrual migraine ( vascular headache

resulting from the hormonal changes.

5. Severe cramping.

6. Emotional changes e.g. Irritability and depression.

Premenstrual Syndrome

Also known as PMS .

Definition : cluster of symptoms that occurs about 7-14days

before the onset of menstrual flow and generally subsides once

the flow begins.

It commonly affects premenopausal females (30-40years old).

Clinical presentation include both physical and emotional

symptoms.

Clinical Presentation of PMS

Emotional

1. Tension or anxiety.

2. Crying spells.

3. Mood swings.

4. Appetite changes.

5. Trouble falling asleep .

6. Social withdrawal.

7. Poor concentration.

Physical

1. Joint or muscle pain.

2. Headache and Fatigue.

3. Weight gain.

4. Abdominal bloating.

5. Breast tenderness.

6. Acne flare-ups.

7. Constipation or diarrhea.

Clinical Presentation of PMS

Symptoms can be exacerbated by :

1. Stress.

2. Diet.

3. Alcohol consumption.

4. drug use.

Emergency presentation of PMS : reactive hypoglycemia,

resulting in increased fatigue.

Premenstrual Tension Syndrome

Prehospital treatment :

Mainly supportive including :

1. Administration of oral or IV

glucose if glucose levels

support.

2. Administration of a small dose

of analgesics or anxiolytics to

reduce patient anxiety .

Mittelschmerz

• Definition : mid cyclic abdominal pain and cramping that

occurs at any time during ovulation usually 2 weeks before the

menstrual flow.

Criteria of the pain

1. midcyclic, with a history of similar pain episodes during

previous periods.

2. Not sever (usually mild).

3. Not referred or radiated.

4. Localized to one side , pain may be reported as "switching

sides" from month to month.

5. Associated with mild nausea and vaginal spotting.

6. Relieved by over the counter analgesic.

Management

1. Assurance and mild analgesics

2. Any persistent or sever pain or associated abnormal

symptoms ( vomiting , diarrhea , fever or abdominal

tenderness ) , should be evaluated by a physician.

Dysmenorrhea

Definition : painful menstruation .

There are two types of dysmenorrhoea :

1. Primary dysmenorrhoea .

2. Secondary dysmenorrhoea .

Primary dysmenorrhoea

No underlying pathology ( functional ).

Occurs at the beginning of menstrual blood flow and lasts for the

first 2 days .

Associated with nausea, vomiting, and diarrhea .

Management :

1. Assurance .

2. Bed rest .

3. Simple analgesics.

Secondary dysmenorrhoea

May signal an underlying pathology.

Present before, during, and after the menstrual flow.

Causes of secondary dysmenorrhoea:

1. Uterine fibroid.

2. Endometriosis.

3. Pelvic inflammatory disease.

4. Chronic pelvic congestion.

5. Intra uterine device.

Menopause

Definition : last menstrual cycle which marks the end of

childbearing age.

Typically begins between the ages of 40 and 50.

The menstrual cycles become less frequent over time and then

stops completely .

Clinical Presentation of Menopause

1. Diaphoresis ( excessive sweating ).

2. Hair loss.

3. Hot flashes (sometimes accompanied by tachycardia).

4. Severe muscle aches and pains.

5. Headache and Vertigo.

6. Dyspnea.

7. Digestive problems.

8. Emotional instability.

Complication of menopause

1. Atherosclerosis.

2. Osteoporosis.

3. Coronary heart disease.

4. Atrophy of genitourinary organs which result in :

Vaginal dryness and discomfort.

Urinary frequency.

Nocturia.

Incontinence.

Menopause

Management

1. Hormone replacement therapy.

2. Calcium .

3. Multivitamins .

Vaginal bleeding

Vaginal bleeding or dysfunctional uterine bleeding is one of the

most frequent reasons that women consult a gynecologist.

1. Hypermenorrhea : Flow of blood lasts several days longer

than normal or is excessive.

2. Polymenorrhea: Blood flow occurs more often than a 24-day

interval.

3. Metrorrhagia: Blood flow or intermittent spotting occurring

irregularly but frequently

Causes of vaginal bleeding

1. Trauma : rape , accident or during sexual intercourse.

2. Infection : vaginitis , cervicitis and endometritis.

3. Tumor : vaginal , cervical or uterine cancer .

4. Specific diseases : ovarian cyst , polycystic ovarian disease

and endometriosis.

5. Systemic disease : thyroid disease and bleeding disorders.

6. Obstetric causes of vaginal bleeding : abortion , ectopic

pregnancy , abruptioplacenta and placenta praevia.

Assessment Stress Points

1. History :

Find out if there is any possibility of pregnancy ,(LNMP).

Include questions about any incidents or events that led up

to the patient requesting EMS.

Determine the amount of blood loss.

Determine if the patient has any pain or discharge

associated with the bleeding.

Determine if the patient uses contraception and what kind.

Indicators of Sever Bleeding From History

1. Quantity .

2. Color : bright red indicates sever bleeding .

3. Associated clots : clots indicates sever bleeding.

4. Duration .

5. Associated symptoms : weakness , fainting and collapse.

Assessment Stress Points

2. Examination : if history suggests significant bleeding ,

assess for signs and symptoms of hypovolemic shock :

a. Orthostatic hypotension (first sign)

b. Resting tachycardia

c. Hypotension.

d. Finally shock .

Management

1. Maintain patent air way , if any signs of shock is present give

high-flow oxygen.

2. Keep the patient warm.

3. Provide IV fluid therapy.

4. If the bleeding is severe, apply dressings to the vaginal area.

5. Maintain professionalism and empathy

Amenorrhea

Definition : Amenorrhea is the absence of menses.

There are two types :

1. Primary amenorrhea : primary amenorrhea is the

failure of menses to occur by age 16 years, in the

presence of normal growth and secondary sexual

characteristics.

2. Secondary amenorrhea : cessation of previously

existing menstruation after menarche has started .

Causes of secondary amenorrhea

1. Pregnancy (most common cause)

2. Exercise

3. Drop of body fat below a certain percentage

4. Emotional problems or extreme stress

5. Anorexia nervosa

Home work

Enumerate :

1. Clinical Presentation of PMS .

2. Criteria of the Mittelschmerz pain .

Differentiate in table between primary and secondry

dysmenorrhoea ??

home work has to be sent to the e-mail in ward format one

day before next week lecture .

Any questions ???