Menstruation disorders and treatment

1. MENSTRUATION
DISORDERS

4. AMENORRHEA

5. 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).

6. 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

7. 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

8. 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.

9. 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.

10. 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:

11. AMENORRHEA: TREATMENT
Pharmacological 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)

12. 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.

13. 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

14. DYSMENORRHEA

15. PREMENSTURAL SYNDROME
Premenstrual 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

16. 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

17. DYSMENORRHEA: DEFINITION
Dysmenorrhea :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.

18. 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

19. DYSMENORRHEA: SIGNS &
SYMPTOMES
Primary 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

20. DYSMENORRHEA:
PHARMACOLOGICAL TREATMENT
NSAIDsare 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 PRN
2- 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

21. 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.

22. 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 consedered
as alternative to hormonal therapy and NSAIDs.

23. 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 .

24. 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

25. DYSMENORRHEA:
NON-
PHARMACOLOGICA
L TREATMENT

26. 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

27. 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.

28. MENORRHAGIA

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

30. 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.

31. 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.

32. 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.

33. 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.

34. Thank you
Hiba, Khadijeh, and Israa