This document discusses disorders of menstruation, including amenorrhea (absence of menstrual period), premenstrual syndrome (PMS), and menorrhagia (heavy menstrual bleeding). Amenorrhea can be primary (periods never start) or secondary (periods stop) and has many potential causes including pregnancy, breastfeeding, menopause, hormonal imbalances, medications, and structural issues. PMS involves physical and emotional symptoms in the one to two weeks before a woman's period, and is thought to be related to cyclic hormone changes. Menorrhagia is heavy or prolonged bleeding and can be caused by hormone imbalances, uterine fibroids, polyps, medications, and other medical conditions. Diagn

1. DISORDERS OF
MENSTRUATION

2. •AMENORRHOEA

3. Introduction:
• Amenorrhoea is the absence of a
menstrual period in a woman of
reproductive age.

4. • Physiological states of amenorrhoea
are seen, most commonly, during
pregnancy and lactation
(breastfeeding), the latter also
forming the basis of a form of
contraception known as the
lactational amenorrhoea method.
• Outside of the reproductive years
there is absence of menses during
childhood and after menopause.

5. Classification of
amenorrhoea:
• Primary amenorrhoea (menstrual cycles
never starting) may be caused by
developmental problems such as,
• the congenital absence of the uterus,
• failure of the ovary to receive or maintain
egg cells.

6. • It is defined as an absence of
secondary sexual characteristics by
age 14 with no menarche or normal
secondary sexual characteristics but
no menarche by 16 years of age.

7. • Secondary amenorrhoea (menstrual
cycles ceasing) is often caused by
hormonal disturbances from the
hypothalamus and the pituitary gland,
from premature menopause or
intrauterine scar formation.
• It is defined as the absence of
menses for three months in a woman
with previously normal menstruation or
nine months for women with a history
of oligomenorrhoea.

8. Causes and risk
factors:
1. Natural amenorrhea
• During the normal course of life,
women may experience amenorrhea
for natural reasons, such as:
• Pregnancy
• Breast-feeding
• Menopause

9. 2. Contraceptives
• Some women who take birth control
pills may not have periods. Even after
stopping oral contraceptives, it may
take some time before regular
ovulation and menstruation return.
Contraceptives that are injected or
implanted also may cause
amenorrhea, as can some types of
intrauterine devices.

10. 3. Medications
• Certain medications can cause
menstrual periods to stop, including
some types of:
• Antipsychotics
• Cancer chemotherapy
• Antidepressants
• Blood pressure drugs
• Allergy medications

11. 4. Lifestyle factors
• Sometimes lifestyle factors contribute to
amenorrhea, for instance:
• Low body weight. Excessively low body
weight — about 10 percent under normal
weight — interrupts many hormonal
functions in your body, potentially halting
ovulation. Women who have an eating
disorder, such as anorexia or bulimia,
often stop having periods because of
these abnormal hormonal changes.

12. • Excessive exercise. Women who
participate in activities that require rigorous
training, such as ballet, may find their
menstrual cycles interrupted. Several
factors combine to contribute to the loss of
periods in athletes, including low body fat,
stress and high energy expenditure.

13. • Stress. Mental stress can temporarily
alter the functioning of your
hypothalamus — an area of your
brain that controls the hormones that
regulate your menstrual cycle.
Ovulation and menstruation may stop
as a result. Regular menstrual
periods usually resume after your
stress decreases.

14. 5. Hormonal imbalance
• Many types of medical problems can
cause hormonal imbalance, including:
• Polycystic ovary syndrome (PCOS).
PCOS causes relatively high and
sustained levels of hormones, rather
than the fluctuating levels seen in the
normal menstrual cycle.

15. • Thyroid malfunction. An overactive
thyroid gland (hyperthyroidism) or
underactive thyroid gland
(hypothyroidism) can cause
menstrual irregularities, including
amenorrhea.

16. • Pituitary tumor. A noncancerous
(benign) tumor in your pituitary gland
can interfere with the hormonal
regulation of menstruation.

17. • Premature menopause. Menopause
usually begins around age 50. But,
for some women, the ovarian supply
of eggs diminishes before age 40,
and menstruation stops.

18. 6. Structural problems
• Problems with the sexual organs
themselves also can cause
amenorrhea. Examples include:
• Uterine scarring. Asherman's
syndrome, a condition in which scar
tissue builds up in the lining of the
uterus, can sometimes occur after a
dilation and curettage (D&C), cesarean
section or treatment for uterine fibroids.
Uterine scarring prevents the normal
buildup and shedding of the uterine
lining.

19. • Lack of reproductive organs.
Sometimes problems arise during
fetal development that lead to a girl
being born without some major part of
her reproductive system, such as her
uterus, cervix or vagina. Because her
reproductive system didn't develop
normally, she can't have menstrual
cycles.

20. • Structural abnormality of the
vagina. An obstruction of the vagina
may prevent visible menstrual
bleeding. A membrane or wall may be
present in the vagina that blocks the
outflow of blood from the uterus and
cervix.

21. Signs and symptoms:
• The main sign of amenorrhea is
the absence of menstrual periods.
Depending on the cause of
amenorrhea, you might experience
other signs or symptoms along with
the absence of periods, such as:
• Milky nipple discharge
• Hair loss

22. • Headache
• Vision changes
• Excess facial hair
• Pelvic pain
• Acne
• Vaginal dryness
• Night sweats

23. Diagnostic evaluation:
• History collection
• Physical examination
• Blood tests may be performed to
determine the levels of hormones
secreted by the pituitary gland (FSH,
LH, TSH, and prolactin) and the
ovaries (estrogen).

24. • Ultrasonography of the pelvis may be
performed to assess the abnormalities
of the genital tract or to look for
polycystic ovaries.
• CT scan or MRI of the head may be
performed to exclude pituitary and
hypothalamic causes of amenorrhea.

25. • If the above tests are inconclusive,
additional tests may be performed
including:
• Thyroid function tests
• Determination of prolactin levels
• Hysterosalpingogram (X-ray test)
which examine the uterus
• Hysteroscopy

26. Management:
• Dopamine agonists such as bromocriptine
(Parlodel) or pergolide (Permax), are
effective in treating hyperprolactinemia. In
most women, treatment with dopamine
agonists medications restores normal
ovarian endocrine function and ovulation.
• Hormone replacement therapy consisting
of an estrogen and a progestin can be used
for women in whom estrogen deficiency
remains because ovarian function cannot be
restored.

27. • Metformin (Glucophage) is a drug
that has been successfully used in
women with polycystic ovary
syndrome to induce ovulation.

28. • In some cases, oral contraceptives may
be prescribed to restore the menstrual
cycle and to provide estrogen
replacement to women with amenorrhea
who do not wish to become pregnant.
• Before administering oral contraceptives,
withdrawal bleeding is induced with an
injection of progesterone or oral
administration of 5-10 mg of
medroxyprogesterone (Provera) for 10
days.

29. • Some pituitary and hypothalamic
tumors may require surgery and, in
some cases, radiation therapy.
• Women with intrauterine adhesions
require dissolution of the scar tissue.

30. •PREMENSTRUAL
SYNDROME
(PMS)

31. Introduction:
• Premenstrual syndrome (PMS) refers
to physical and emotional symptoms
that occur in the one to two weeks
before a woman's period. Symptoms
often vary between women and
resolve around the start of bleeding.

32. • Common symptoms include acne,
tender breasts, bloating, feeling tired,
irritability, and mood changes. Often
symptoms are present for around six
days.
• Premenstrual dysphoric disorder
(PMDD) is a more severe form of PMS
that has greater psychological
symptoms.

33. Causes and risk
factors:
• Exactly what causes premenstrual
syndrome is unknown, but several
factors may contribute to the
condition:
• Cyclic changes in hormones. Signs
and symptoms of premenstrual
syndrome change with hormonal
fluctuations and disappear with
pregnancy and menopause.

34. • Chemical changes in the brain.
Fluctuations of serotonin, a brain
chemical (neurotransmitter) that is
thought to play a crucial role in mood
states, could trigger PMS symptoms.
Insufficient amounts of serotonin may
contribute to premenstrual
depression, as well as to fatigue, food
cravings and sleep problems.

35. Clinical
manifestations:
Emotional and behavioral
symptoms
• Tension or anxiety
• Depressed mood
• Crying spells
• Mood swings and irritability or anger

36. • Appetite changes and food cravings
• Trouble falling asleep (insomnia)
• Social withdrawal
• Poor concentration

37. Physical signs and symptoms
• Joint or muscle pain
• Headache
• Fatigue
• Weight gain related to fluid retention
• Abdominal bloating
• Breast tenderness
• Acne
• Constipation or diarrhea

38. Diagnostic evaluation:
• There are no unique physical
findings or laboratory tests to
positively diagnose premenstrual
syndrome.

39. Management:
• Antidepressants. Selective serotonin
reuptake inhibitors (SSRIs) — which
include fluoxetine (Prozac, Sarafem),
paroxetine (Paxil, Pexeva), sertraline
(Zoloft) and others — have been
successful in reducing mood symptoms.
SSRIs are the first line treatment for
severe PMS or PMDD. These drugs are
generally taken daily. But for some
women with PMS, use of
antidepressants may be limited to the
two weeks before menstruation
begins.

40. • Nonsteroidal anti-inflammatory
drugs (NSAIDs). Taken before or at
the onset of your period, NSAIDs
such as ibuprofen (Advil, Motrin IB,
others) or naproxen (Aleve,
Naprosyn, others) can ease cramping
and breast discomfort.

41. • Diuretics. When exercise and limiting
salt intake aren't enough to reduce
the weight gain, swelling and bloating
of PMS, taking water pills (diuretics)
can help your body shed excess fluid
through your kidneys.
Spironolactone (Aldactone) is a
diuretic that can help ease some of
the symptoms of PMS.

42. • Hormonal contraceptives. These
prescription medications stop
ovulation, which may bring relief from
PMS symptoms.

43. Modify diet:
• Eat smaller, more-frequent meals to reduce
bloating and the sensation of fullness.
• Limit salt and salty foods to reduce bloating
and fluid retention.
• Choose foods high in complex carbohydrates,
such as fruits, vegetables and whole grains.
• Choose foods rich in calcium. If you can't
tolerate dairy products or aren't getting
adequate calcium in your diet, a daily calcium
supplement may help.
• Avoid caffeine and alcohol.

44. Incorporate exercise into
regular routine
• Engage in at least 30 minutes of brisk
walking, cycling, swimming or other
aerobic activity most days of the
week. Regular daily exercise can help
improve your overall health and
alleviate certain symptoms, such as
fatigue and a depressed mood.

45. Reduce stress
• Get plenty of sleep.
• Practice progressive muscle
relaxation or deep-breathing
exercises to help reduce headaches,
anxiety or trouble sleeping
(insomnia).
• Try yoga or massage to relax and
relieve stress.

46. Record symptoms for a few
months
• Keep a record to identify the triggers
and timing of your symptoms. This
will allow you to intervene with
strategies that may help to lessen
them.

47. •MENORRHAGIA:

48. Introduction:
• It is the most common type of
abnormal uterine bleeding
characterized by heavy and
prolonged menstrual bleeding. In
some cases, bleeding may be so
severe and daily activities become
interrupted.

49. • A normal menstrual cycle 21-35 days
in duration, with bleeding lasting an
average of 5 days and total blood
flow between 25 and blood of greater
than 80 ml or lasting longer than 7
days constitutes menorrhagia.

50. Causes and risk
factors:
• Hormone imbalance. In a normal
menstrual cycle, a balance between
the hormones estrogen and
progesterone regulates the buildup
of the lining of the uterus
(endometrium), which is shed during
menstruation. If a hormone imbalance
occurs, the endometrium develops in
excess and eventually sheds by way
of heavy menstrual bleeding.

51. • Dysfunction of the ovaries. If
ovaries don't release an egg (ovulate)
during a menstrual cycle
(anovulation), your body doesn't
produce the hormone progesterone,
as it would during a normal menstrual
cycle. This leads to hormone
imbalance and may result in
menorrhagia.

52. • Uterine fibroids. These
noncancerous (benign) tumors of the
uterus appear during your
childbearing years. Uterine fibroids
may cause heavier than normal or
prolonged menstrual bleeding.

53. • Polyps. Small, benign growths on the
lining of the uterus (uterine polyps)
may cause heavy or prolonged
menstrual bleeding. Polyps of the
uterus most commonly occur in
women of reproductive age as the
result of high hormone levels.

54. • Adenomyosis. This condition occurs
when glands from the endometrium
become embedded in the uterine
muscle, often causing heavy bleeding
and painful menses.

55. • Intrauterine device (IUD).
Menorrhagia is a well-known side
effect of using a nonhormonal
intrauterine device for birth control.
When an IUD is the cause of
excessive menstrual bleeding, may
need to remove it.

56. • Pregnancy complications. A single,
heavy, late period may be due to a
miscarriage. If bleeding occurs at the
usual time of menstruation, however,
miscarriage is unlikely to be the
cause. An ectopic pregnancy —
implantation of a fertilized egg within
the fallopian tube instead of the
uterus — also may cause
menorrhagia.

57. • Cancer. Rarely, uterine cancer,
ovarian cancer and cervical cancer
can cause excessive menstrual
bleeding.

58. • Inherited bleeding disorders. Some
blood coagulation disorders — such
as von Willebrand's disease, a
condition in which an important blood-
clotting factor is deficient or impaired
— can cause abnormal menstrual
bleeding.

59. • Medications. Certain drugs,
including anti-inflammatory
medications and anticoagulants, can
contribute to heavy or prolonged
menstrual bleeding.

60. • Other medical conditions. A
number of other medical
conditions, including pelvic
inflammatory disease (PID),
thyroid problems,
endometriosis, and liver or
kidney disease, may be
associated with menorrhagia.

61. Clinical
Manifestations:
• Soaking through one or more sanitary
pads or tampons every hour for
several consecutive hours
• Needing to use double sanitary
protection to control your menstrual
flow
• Needing to wake up to change
sanitary protection during the night

62. • Bleeding for longer than a week
• Passing blood clots with menstrual
flow for more than one day
• Restricting daily activities due to
heavy menstrual flow
• Symptoms of anemia, such as
tiredness, fatigue or shortness of
breath.

63. Diagnostic evaluation:
• History collection
• Physical examination
• Blood tests. A sample of your blood
may be evaluated for iron deficiency
(anemia) and other conditions, such
as thyroid disorders or blood-clotting
abnormalities.

64. • Pap test. In this test, cells from your
cervix are collected and tested for
infection, inflammation or changes
that may be cancerous or may lead to
cancer.
• Endometrial biopsy. Your doctor
may take a sample of tissue from the
inside of your uterus to be examined
by a pathologist.

65. • Ultrasound scan. This imaging
method uses sound waves to
produce images of your uterus,
ovaries and pelvis.
• Based on the results of your initial
tests, doctor may recommend further
testing, including:

66. • Sonohysterogram. During this test, a
fluid is injected through a tube into your
uterus by way of your vagina and cervix.
Your doctor then uses ultrasound to look
for problems in the lining of your uterus.
• Hysteroscopy. This exam involves
inserting a tiny camera through your
vagina and cervix into your uterus,
which allows your doctor to see the
inside of your uterus.

67. Management:
• Iron supplements. If you also have
anemia, your doctor may recommend
that you take iron supplements
regularly. If your iron levels are low
but you're not yet anemic, you may
be started on iron supplements rather
than waiting until you become
anemic.

68. • Nonsteroidal anti-inflammatory
drugs (NSAIDs). NSAIDs, such as
ibuprofen (Advil, Motrin IB, others) or
naproxen (Aleve), help reduce
menstrual blood loss. NSAIDs have
the added benefit of relieving painful
menstrual cramps (dysmenorrhea).

69. • Tranexamic acid. Tranexamic acid
(Lysteda) helps reduce menstrual
blood loss and only needs to be taken
at the time of the bleeding.

70. • Oral contraceptives. Aside from
providing birth control, oral
contraceptives can help regulate
menstrual cycles and reduce
episodes of excessive or prolonged
menstrual bleeding.

71. • Oral progesterone. When taken for
10 or more days of each menstrual
cycle, the hormone progesterone can
help correct hormone imbalance and
reduce menorrhagia.

72. • The hormonal IUD (Mirena). This
intrauterine device releases a type of
progestin called levonorgestrel,
which makes the uterine lining thin
and decreases menstrual blood flow
and cramping.

73. • Dilation and curettage (D&C). In this
procedure, your doctor opens (dilates)
your cervix and then scrapes or
suctions tissue from the lining of your
uterus to reduce menstrual bleeding.
Although this procedure is common and
often treats acute or active bleeding
successfully, you may need additional
D&C procedures if menorrhagia recurs.

74. • Uterine artery embolization. For
women whose menorrhagia is caused
by fibroids, the goal of this procedure
is to shrink any fibroids in the uterus
by blocking the uterine arteries and
cutting off their blood supply.

75. • Focused ultrasound ablation.
Similar to uterine artery embolization,
focused ultrasound ablation treats
bleeding caused by fibroids by
shrinking the fibroids. This procedure
uses ultrasound waves to destroy the
fibroid tissue. There are no incisions
required for this procedure.

76. • Myomectomy. This procedure
involves surgical removal of uterine
fibroids. Depending on the size,
number and location of the fibroids,
surgeon may choose to perform the
myomectomy using open abdominal
surgery, through several small
incisions (laparoscopically), or
through the vagina and cervix
(hysteroscopically).

77. • Endometrial ablation. Using a variety
of techniques, doctor permanently
destroys the lining of your uterus
(endometrium). After endometrial
ablation, most women have much lighter
periods.

78. • Endometrial resection. This surgical
procedure uses an electrosurgical
wire loop to remove the lining of the
uterus. Both endometrial ablation and
endometrial resection benefit women
who have very heavy menstrual
bleeding. Pregnancy isn't
recommended after this procedure.

79. • Hysterectomy. Hysterectomy —
surgery to remove your uterus and
cervix — is a permanent procedure
that causes sterility and ends
menstrual periods. Hysterectomy is
performed under anesthesia and
requires hospitalization. Additional
removal of the ovaries (bilateral
oophorectomy) may cause premature
menopause.

80. Summary

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