MENSTRUATION DISORDERS

AMENORRHEA

AMENORRHEA: DEFINITION

* Normally, woman goes through regular monthly cycle called menstruation.

* some problems can impedes the cycle

* Amenorrhea: is the absence of menstruation. May be primary or secondary

* Primary amenorrhea is the absence of menstrual bleeding and secondary sexual characteristics in a girl by age 14 years or the absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 years.

* Secondary amenorrhea is the absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for three or more months (3 cycles or more).

AMENORRHEA: ETIOLOGY

• Functional causes

- Anorexia/bulimia

- Chronic diseases (for example, tuberculosis)

- Excessive weight gain or weight loss

- Depression , Psychotropic drug use (drugs prescribed to stabilize or improve mood, mental status, or behavior)

- Excessive stress, Excessive exercise

- Cycle suppression with systemic hormonal contraceptive pills

Structural causes:

• Hypergonadotropic hypogonadism

Premature ovarian failure

Hypogonadotropic hypogonadism

Hypothalamic hypogonadism

Pituitary disease

Thyroid disease

Absence of the uterus, cervix, or vagina

Pregnancy

Hyperprolactinemia

Elevated levels of androgens (male hormones)

Polycystic ovary syndrome PCOS

AMENORRHEA: SIGNS AND SYMPTOMS •Milky nipple discharge.

•Unwanted hair growth.

•Headache.

•Vision changes.

•Excess facial hair.

•Pelvic pain.

•Acne

•stops having menstrual periods for three cycles in a row.

AMENORRHEA: TREATMENT

Non-pharmacological treatment:

- women should eat a properly balanced diet.

- women should restrict the amount of fat in their diet

- A moderate exercise program may restore normal menstruation.

- restore and maintain a healthy body weight.

- finding ways to deal with stress and conflicts may help.

- Maintaining a healthy lifestyle by avoiding alcohol consumption and cigarette smoking is also helpful.

AMENORRHEA: TREATMENT

For primary amenorrhea, depending on age and the results of the ovary function test, health care providers may recommend watchful waiting. If an ovary function test shows low follicle-stimulating hormone (FSH) or luteinizing hormone (LH) levels, menstruation may just be delayed. In females with a family history of delayed menstruation, this kind of delay is common.

Treatment for secondary amenorrhea, depending on the cause, may include:

AMENORRHEA: TREATMENTPharmacological treatment:

Drugs used in polycystic ovary syndrome to induce ovulation:

Metformin (Metformin, TEVA) and

Clomiphene citrate (Ikaclomin, TEVA), (Ovaclomin, BZ)

• Dopamine receptor agonists; for treating hyperprolactinemia:

Bromocriptine (Lactopar, BZ)

Cabergoline (Dostinex, Pfizer), (Goline, BZ)

Hormone replacement therapy HRT consisting of an estrogen and/or a progestrone can be used in estrogen deficiency:

Dydrogesterone (Duphaston, Abbott)

Progesterone micronized (Utrogestan, CTS)

Medroxyprogestrone acetate (Provera, Pfizer) (Oralut, BZ)

Norethistterone acetate (Primolut-Nor, BAYER) (Premo-Nor, BZ)

In some cases, oral contraceptives may be prescribed to restore the menstrual cycle. Before administering oral contraceptives, withdrawal bleeding is induced with an injection of progesterone or oral administration of 5-10 mg of medroxyprogesterone for 10 days.

SIDE EFFECTS:

• dizziness, spinning sensation, mild drowsiness

• mild headache, depressed mood, sleep problems (insomnia)

• upset stomach, nausea, vomiting, stomach pain, loss of appetite, diarrhea, constipation

• acne, hair growth or hair loss

• changes in menstrual periods, vaginal itching or discharge

• changes in appetite, increased or decreased weight

DYSMENORRHEA

PREMENSTURAL SYNDROMEPremenstrual symptoms occur between ovulation and the start of menstrual bleeding(one to two weeks before a woman's period)

Common physical symptoms

- Bloating , weight gain

- Fatigue , lack of energy

- Cramps ,aching muscles and joints, low back Paine

- Sleeping too much or too little

- Constipation and diarrhea

- Acne

Mood and behavior symptoms

- Sad or depressed mood

- Anger, irritability, aggression

- Anxiety

- Mood swings

- Decreased alertness, trouble concentrating

- Withdrawal from family and friends

PREMENSTRUAL DYSPHORIC DISORDER (PMDD)- PMDD is characterized by depressed or labile mood, anxiety, irritability, anger, and other symptoms occurring exclusively during the 2 weeks preceding menses. Other symptoms may include the following:

• Decreased interest in usual activities (eg, work, school, friends, and hobbies)

• Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain

- It have more sever symptoms when compered with PMS

DYSMENORRHEA: DEFINITIONDysmenorrhea :painful cramps that may occur immediately before or during the menstrual period.

There are two types of dysmenorrhea: primary and secondary dysmenorrhea:

• Primary dysmenorrhea is cramping pain in the lower abdomen occurring just before or during menstruation, in the absence of other diseases such as endometriosis.

• Secondary dysmenorrhea is pain caused by a disorder in the woman's reproductive organs, such as endometriosis, adenomyosis, uterine fibroids, or infection. Pain from secondary dysmenorrhea usually begins earlier in the menstrual cycle and lasts longer than common menstrual cramps.

DYSMENORRHEA: ETIOLOGY

Risk factors for primary dysmenorrhea include the following:

- Early age at menarche (< 12 years)

-Nulliparity

- Heavy or prolonged menstrual flow

- Smoking

- Positive family history

- Obesity

Risk factors for secondary dysmenorrhea include the following :

- Leiomyomata (fibroids)

- Pelvic inflammatory disease

- Tubo-ovarian abscess

- Ovarian torsion

- Endometriosis

DYSMENORRHEA: SIGNS & SYMPTOMESPrimary dysmenorrhea

• Onset shortly after the first occurrence of menstruation (≤6 months)

• Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow)

• Cramping or laborlike pain

• lower abdominal pain, radiating to the back or thigh .

Secondary dysmenorrhea

• Dysmenorrhea beginning in the 20s or 30s, after previous relatively painless cycles .

• Heavy menstrual flow or irregular bleeding

• Dysmenorrhea occurring during the first or second cycles after menarche (menarch is the first occurrence of menstruation)

• Pelvic abnormality with physical examination

• Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives (OCs)

• Infertility

• Dyspareunia

• Vaginal discharge

DYSMENORRHEA: PHARMACOLOGICAL TREATMENT

NSAIDs are common treatment for both primary and secondary dysmenorrheaNSAIDs are highly effective in treating dysmenorrhea, especially when they are started before the onset of menses and continued through day 2. They decrease menstrual pain by decreasing intrauterine pressure and lowering prostaglandin F2α .

The most common side effect of NSAIDs is the GI upset.

NSAIDs approved by the FDA for treatment of dysmenorrhea are as follows:

1-Diclofenac Immediate-release (Cataflam): 100 mg PO once, then 50 mg PO q8hr PRN2- Ibuprofen OTC: 200-400 mg PO q4-6hr; not to exceed 1.2 g unless directed by physician

Prescription: 400-800 mg PO/IV q6hr

3-Ketoprofen Immediate-release: 25-50 mg q6-8hr PRN.

4-Meclofenamate

5-Mefenamic acid for Primary Dysmenorrhea ,Initial 500 mg PO once, Then250 mg PO q6hr PRN usually not to exceed 3 days

6-Naproxen :500 mg PO initially, then 250 mg PO q6-8hr or 500 mg PO q12hr (long-acting formula); not to exceed 1250 mg/day on first day; subsequent doses should not exceed 1000 mg/day.

Other NSAIDs and analgesics that have been used include the following:

Aspirin may not be as effective as these NSAIDs, and acetaminophen may be a useful adjunct for alleviating only mild menstrual cramping pain, and both aspirin and acetaminophen are used when other NASID are not tolerated .

COX-2 inhibitors have also been used in relieving menstrual pain. They selectively inhabit COX-2 receptor and reduse GI symptoms. But NASID remain better .

Montelukast : they reduce menstrual pain. They are consederedas alternative to hormonal therapy and NSAIDs.

OCs may be an appropriate choice for patients who are not

planning to be pregnant . Combination OCs suppress the hypothalamic-pituitary-ovarian axis, thereby inhibiting ovulation and preventing prostaglandin production.

Although not approved by the FDA for treating dysmenorrhea, the

following OCs are also used:

1-Combination OCs (eg, ethinyl estradiol with progestin or drospirenone) .

2-Levonorgestrel intrauterine device .

3-Depot medroxyprogesterone acetate .

Analgesics In an emergency setting, patients who do not respond to NSAIDs may require treatment with narcotics for pain control.

Moderate to Severe Pain

1-2 tablets (2.5-10 mg hydrocodone; 300-325 mg acetaminophen) PO q4-6hr PRN

Acetaminophen: Not to exceed 1 g/dose or 4 g/24 hr

Hydrocodone: Maximum daily dose should not exceed 60 mg/24 hr

DYSMENORRHEA: NON-PHARMACOLOGICAL TREATMENT

Non pharmacological treatment :

1. Exercise

2. Heat. Using a hot bath or a heating pad, hot water bottle or heat patch on your lower abdomen may ease menstrual cramps.

3. Dietary supplements. A number of studies have indicated that vitamin E, omega-3 fatty acids, vitamin B-1 (thiamine), vitamin B-6 and magnesium supplements may effectively reduce menstrual cramps.

4. Avoiding alcohol and tobacco. These substances can make menstrual cramps worse.

5. Reducing stress. Psychological stress may increase your risk of menstrual cramps and their severity.

DYSMENORRHEA: NON-PHARMACOLOGICAL TREATMENT

primary dysmenorrhea is treataed by relief cramping pelvic pain and associated symptoms that accompany menstrual flow. (NSAIDs) and (OCs) are the most commonly used as treatment for the management of primary dysmenorrhea.

secondary dysmenorrhea is treated by correction of the underlying organic cause(treat pelvic pathology like endometriosis) . use of analgesic agents and narcotics as adjunctive therapy may be beneficial.

MENORRHAGIA

MENORRHAGIA: DEFINITION

is a menstrual period with abnormally heavy flow and falls under the larger category of abnormal uterine bleeding (AUB).

MENORRHAGIA: SIGNS & SYMPTOMES- saturation of one or more sanitary pads or tampons every hour

for several hours .

- use of double sanitary protection

- Menstrual flow or bleeding lasting more than 1 week

- Passage of blood clots which are the size of a quarter or larger

- Signs and symptoms of anemia which include tiredness, fatigue and shortness of breath Constant lower abdominal and pelvic pain.

MENORRHAGIA: ETIOLOGY

•Hormonal disturbances

•Ovarian dysfunction

• Uterine fibroids

• Intrauterine Device (IUD)

•Pregnancy-related complications such as a miscarriage cervical or ovarian cancers Inherited bleeding disorders such

•Platelet function disorder Medications, such as anti-inflammatory and anticoagulants

•thyroid disorders,

•endometriosis,

•and liver or kidney disease.

MENORRHAGIA: PHARMACOLOGICAL THERAPY• iron supplementation to treat anemia

• NSAIDs: Ibuprofen, Naproxen...

• Oral contraceptives

• Oral progesterone: levonorgestrel (Microlut, BAYER)

Medroxyprogestrone acetate (Provera, Pfizer) (Oralut, BZ)

• Anti-fibrinolytic drug: tranexamic acid (Hexakapron, TEVA), used in the treatment of hemorrhages.

MENORRHAGIA: NON-PHARMACOLOGICAL THERAPY•Ginger

•Cinnamon

•Mustard seeds

•Omega -3

•Diet: Diet should be rich in vitamins and minerals like magnesium , iron and calcium .The diet should contain lots of fresh fruits and vegetables, green vegetables.

Thank you

Hiba, Khadijeh, and Israa