This document defines dysmenorrhea and amenorrhea, discusses their causes, symptoms, diagnosis, and management. Dysmenorrhea is painful menstruation that can be primary, caused by prostaglandins, or secondary, due to underlying conditions. Symptoms include cramping pain relieved by NSAIDs, birth control, or heat. Amenorrhea is the absence of menstruation and can be primary or secondary. Causes include hypothalamic, pituitary, or ovarian dysfunction. Evaluation involves examining for secondary sex characteristics and testing hormone levels. Management aims to address the underlying cause, enable fertility if desired, and prevent complications through hormone replacement if needed.

1. 1
Dysmenorrhea

2. OBJECTIVES
By the end of this session, you are expected to:
• Define dysmenorrhea
• Differentiate types of dysmenorrhea
• Discuss management of dysmenorrhea

3. Normal menstruation
• Normal menstruation is defined as:
• Frequency – 21 to 40 days.
• Regularity – Variation ≤7 to 9 days b/n the shortest to
longest cycles.
• Duration – ≤8 days.
• Volume –≤80 mL vaginal "blood" loss per cycle.
• The menstrual fluid is normally non-clotting because a
fibrinolysin is released along with the necrotic
endometrial material.

4. Menstrual disorders
1. DYSMENORRHOEA- Painful menstruation.
• It is one of the most common women’s problems.
• Most common in adolescence, usually 4-5yrs of menarche.
• Painful periods become less common as women age.
CAUSE OF DYSMENORRHEA
• Prostaglandins are chemicals that are formed in the lining of the
uterus during menstruation.
• These prostaglandins cause muscle contractions in the Ux, w/c
cause pain & decrease blood flow & oxygen to the Ux.
• Similar to labor pains, cause significant pain & discomfort.

5. TYPES
A. Primary(spasmodic)dysmenorrhea-
• Presence of recurrent, crampy, lower abdominal pain that
occurs during menses in the absence of disease
 Due to prostaglandin-induced Uterine contractions and
ischemia.
 Begins 6 months - 2 years after menarche.
• MECHANISMS: Excess production of endometrial PGF2 &
E2, but not plasma.
• These compounds can cause dysrhythmia Ux contractions,
hyper-contractility, and increased Ux muscle tone leading to
ischemia.
• They also can account for nausea, vomiting, and diarrhea

6. B. Secondary dysmenorrhea
 Menstrual pain due to organic disease.
 This is rare before 25 years, worsens with age.
 Associated dyspareunia, AUB, infertility.
 Involves an underlying physical cause,
– Endometriosis – Uterine fibroids.
– Adenomyosis -- Ovarian cysts
– Pelvic inflammatory disease (PID).
– Use of an intrauterine device (IUD).
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7. DYSMENORRHEA SYMPTOMS
• The pain of dysmenorrhea is crampy and usually located in
lower abdomen above the pubic bone, back or thighs.
• BEGINS just before or as menstrual bleeding begins, and
gradually diminishes over one to three days.
• Usually occurs intermittently, ranging from mild to disabling.
• Other symptoms that may accompany cramping include
nausea, diarrhea, dizziness, fatigue, headache- cramping
upset stomach & hormonal fluctuation.

8. DIAGNOSIS OF DYSMENORRHEA
• BASED upon a woman's medical history and physical exam.
PHYSICAL EXAMINATION
 Complete abdominal and pelvic examination.
 During the examination- observe and feel the size and
shape of the Vx, Cx, Ux, and ovaries.
• An internal pelvic examination may not be necessary in
adolescent girls.
Other tests
• In some women, pelvic U/S (vaginally if possible) can be
useful in determining if conditions such as Ux fibroids,
adenomyosis, or endometriosis are present.

9. DYSMENORRHEA TREATMENT
• Number of Treatments are available
NSAIDs
 NSAIDs are most effective if started early (for 2-3 days).
 NSAIDs; are prostaglandin syntheses inhibitors- often
alleviate the symptoms of primary dysmenorrhea.
– Prescribe ibuprofen 400-600 mg every 4-6hrs or 800 mg
every 8hrs to a max. dose of 2400 mg per day.

10. DYSMENORRHEA TREATMENT……
• Birth control pills - Birth control pills and other forms
of hormonal birth control (one active tablet for 42
consecutive days).
 Decrease the uterine contractions and menstrual
bleeding that contribute to pain and cramping.
• Intrauterine device (IUD) - contains the hormone
levonorgestrel (Mirena, Skyla, Liletta) can reduce
dysmenorrhea by as much as 50 percent.

11. Non-pharmacologic Rxs - do not require the use of
medication.
• In some cases, these treatments are not as effective as
medications.
• Heat - Apply heat to the lower abdomen with a heating pad,
hot water bottle speed the relief of pain.
• Exercise and sexual activity- has a number of benefits,
so it is reasonable to try exercising to reduce painful periods.
• Sexual activity may be helpful.
• Anecdotal experience suggests menses-related discomfort is
relieved by orgasm in some women – release of endorphin.
DYSMENORRHEA TREATMENT……

12. Amenorrhea

13. OBJECTIVES
By the end of this session, you are expected to:
• Define Amenorrhea
• Differentiate types of Amenorrhea
• Discuss management of Amenorrhea

14. Amenorrhea
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Events of Puberty
Thelarche (breast development)
 Requires estrogen.
Pubarche/adrenarche (pubic hair development)
 Requires androgens.
Menarche（the first menses) Requires:
 GnRH from the hypothalamus.
 FSH and LH from the pituitary.
 Estrogen and progesterone from the ovaries.
 Normal outflow tract.

15. 1. Primary - absence of menarche by age 15 years or
2. Secondary - absence of menses for more than 3months in
girls/women who previously had regular menstrual cycles or
 Six months in girls/women who had irregular menses).
• Missing a single menstrual period may not be important to
assess.
• Absence of menses can be a transient, intermittent, or
permanent condition resulting from dysfunction of
 The hypothalamus, pituitary, ovaries, Ux, or Vx.
Definition of Amenorrhea

16. CAUSES
• Primary amenorrhea is usually the result of a genetic or
anatomical abnormality.
 However, all causes of secondary amenorrhea can
also be causes for primary amenorrhea.
• Gonadal dysgenesis, including Turner syndrome – 43 %.
• Müllerian agenesis (absence of vagina & uterus) – 15 %.
• Polycystic ovary syndrome (PCOS) – 7 %.
• Transverse vaginal septum – 3 %.
• Weight loss/anorexia nervosa – 2 %.
• Hypopituitarism – 2 %.

17. Possible results of amenorrhea
1. Cannot conceive.
2. Lead to osteoporosis and genital atrophy.
2. Increased endometrial hyperplasia  endometrial Ca
from unopposed estrogen secretion.
 Without 2o sexual chxs may give rise to major social and
psychosexual problems.
 Classification of The Main of amenorrhea
• Hypothalamic amenorrhea.
• Pituitary amenorrhea.
• Ovarian amenorrhea.
• Uterine amenorrhea.
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18. 1-Hypothalamic amenorrhea
Low energy availability (from decreased caloric
intake, excessive energy expenditure, or both) and
Stress are common causes of hypo gonadotropic hypo-
gonadism in women.
Etiology
– Psychological stress, Anorexia nervosa, weight loss,
Increased exercise levels.
– Kallmann syndrome-congenital absence of GnRH.
– Drug-induced amenorrhea: anti-psychotics, reserpine,
Contraceptive, Space-occupying lesion of CNS.
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19. Weight-related amenorrhoea: Anorexia Nervosa
• Anorexia nervosa is an eating d/r that makes
people want to weigh less than is healthy.
• A body mass index (BMI) <17 kg/m²
menstrual irregularity and amenorrhea.
• Hypothalamic suppression.
• Low estradiol  risk of osteoporosis
• Low energy availability can suppress the
hypothalamic-pituitary-ovarian (HPO) axis,
 diverting energy away from reproductive
processes to more vital systems 19

20. Exercise-associated amenorrhea
• Common in women who participate in sports.
• Strenuous exercise that is not matched by energy intake
increases the likelihood of menstrual dysfunction.
• Eating disorders have a higher prevalence in female
athletes than non-athletes.
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21. Stress
• Stressors activate the hypothalamic-pituitary-adrenal (HPA)
axis,
 with increased secretion of hypothalamic corticotropin-
releasing hormone (CRH), corticotropin (ACTH), and
adrenal cortisol secretion.
• CRH inhibits GnRH pulse frequency, and cortisol suppresses
reproductive function at the hypothalamic, pituitary, and
uterine levels.
• Extreme physical, nutritional, and/or emotional stress
negatively affect reproduction throughout the HPO axis.

22. Contraception related amenorrhea
• Depo
– 80 % of women will have amenorrhea after 1 year of use.
– It is reversible (estrogen deficiency).
• A minority of women taking the POP may have reversible long
term amenorrhea due to complete suppression of ovulation
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23. 2-pituitary amenorrhea
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Etiology
• Pituitary inability to secrete gonadotropins.
• Pituitary necrosis following massive obstetric hemorrhage is
most common cause in women.
• Diagnosis : History and  E2,FSH,LH
Treatment :
 Replacement of deficient hormones.

24. 3-ovarian amenorrhea
Etiology
◆Gonadal dysgenesis
• Chromosomally incompetent.
- Classic turner’s syndrome (45XO)
• Chromosomally competent
- 46XX (Pure gonadal dysgenesis)
- 46XY (Swyer’s syndrome)
◆Resistant ovary syndrome
◆POS
◆Premature ovarian failure-menopause occurs before 40
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25. 4- Uterine
Etiology
• Uterine amenorrhea
– Absence of uterus
– Utero-vaginal agenesis-15% of primary amenorrhea
– Asherman syndrome
• Anatomic abnormalities of the reproductive tract
– Imperforate hymen.
Diagnosis of amenorrhea
• History
• Physical examination
– PE begins with vital signs, including height and wt
– Laboratory evaluation: hormonal profile. 25

26. Evaluation of Primary Amenorrhea
– Physical exam to determine presence of uterus.
– FSH
– Karyotype
• Is there normal development of secondary sexual
characteristics? NO
 Think hypogonadism or hypogonadotropism
• Is there normal development of secondary sexual
characteristics?YES
Think: Pregnancy, Mullerian anomaly, Androgen insensitivity
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27. Evaluation of Secondary Amenorrhea
History
– Nutrition/exercise habits, weight change
– Sexual / contraceptive practice
– History of uterine/cervical surgery
• Physical exam
– Height/weight
– Hirsutism
– Galactorrhea
– Estrogen status of tissues
• Laboratory
– hCG PRL & TSH  progesterone challenge  FSH  if
high karyotype 27

28. Management of Primary Amenorrhea
• Treatment of primary amenorrhea is directed at correcting
the underlying pathology (if possible)
• Helping the woman to achieve fertility, and
• Prevention of complications of the disease process (e.g.
estrogen replacement to prevent osteoporosis).
• Psychological counseling is particularly important in patients
with absent müllerian structures and/or a Y chromosome.
• Surgery may be required in patients with either congenital
anatomic lesions or Y chromosome material.
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29. Management of Primary ....
• In with hypoestrogenism, hormone replacement is important
to prevent bone loss and potential excess risk of premature
coronary heart disease.
• Functional hypothalamic amenorrhea can usually be
reversed by
 weight gain, reduction in the intensity of
exercise, and/or resolution of illness or emotional stress.
• For women who want to continue to exercise or are unable
to improve their nutritional health,
 estrogen-progestin replacement therapy to those not
seeking fertility to improve bone mineral density
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30. Management of Secondary Amenorrhea
The overall goals of management in women with secondary
amenorrhea include:
• Correcting the underlying pathology, if possible
• Helping the woman to achieve fertility, if desired
• Preventing complications of the disease process (eg,
estrogen replacement to prevent osteoporosis)
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31. Thank you !!