The term metrorrhagia is often used for irregular menstruation that occurs between the expected menstrual periods. Oligomenorrhea is the medical term for infrequent, often light menstrual periods (intervals exceeding 35 days). Amenorrhea is the absence of a menstrual period in a woman of reproductive age.

1. MENSTRUATION &
MENSTRUAL DISORDERS

2. Key terms and definitions
• Menarche: Age at onset of menstruation
• Primary amenorrhea: Absence of menstruation despite
signs of puberty
• Secondary amenorrhea: Absence of menstruation for
3-6 months in a woman who previously menstruated
• Dysfunctional uterine bleeding: Irregular bleeding due
to anovulation or anovulatory cycle
• Oligomenorrhea: Menstrual interval greater than 35
days

3. Key terms and definitions
• Menorrhagia: Regular menstrual intervals, excessive
flow and duration
• Metrorrhagia: Irregular menstrual intervals, excessive
flow and duration
• Anovulation / anovulatory: Menstrual cycle without
ovulation
• Mittleschmertz: Pain with ovulation
• Molimina: Symptoms preceding menses
• Dysmenorrhea: Menstrual cramping/pain

4. Overview
• Normal Menstruation
• Dysmenorrhea
• Abnormal Bleeding
o Pregnancy related
o Anovulation
o Anatomic causes
o Age-specific evaluation
• Amenorrhea

5. Source Undetermined
Normal Menstrual Cycle

6. Normal Menstruation
• Highest rate of an ovulatory cycles <20 or >40 yrs. of age
• Duration of flow 2-8 days
• Amount of flow dependent on how rapid endometrium sheds
• Incomplete shedding = heavier flow, blood loss anemia
Menarche age 12
9 years 16 years

7. Normal Menstruation
• Count from 1st day of flow
• Normal 21-35 days
• 14 day luteal phase
• Cyclic events
o Vaginal discharge
o Mittleschmertz
o Molimina
o PMS

8. Source Undetermined

9. Amenorrhea
Absence of menses during the reproductive year's
categories of amenorrhea:-
categories of amenorrhea:-
A: Primary amenorrhea: is defined as:-
- Absence of menses by age 14 with absence of growth
and development of secondary sexual characters.
- Absence of menses by age 16 with normal development
of secondary sexual chch.
B: secondary amenorrhea: is the absence of menses for
3 cycles or 6 months in women who have previously
menstruated regularly.

10. Etiology
Causes of primary amenorrhea:
1- Extreme wt gain or loss.
2- Congenial abnormalities of the reproductive
system.
3- Stress from a major life event.
4- Excessive exercises
5- Eating disorders (anorexia nervosa)
6- Polycystic ovarian syndrome.
7- Hypothyroidism.

11. Causes of primary amenorrhea
8- Turner syndrome.
9- Imperforated hymen.
10- Chronic illness
11- Pregnancy.
12- Cystic fibrosis.
13- Congenial heart disease.
14- Ovarian or adrenal tumors.

12. Causes of secondary
amenorrhea
• Breast feeding
• Emotional stress
• Mal nutrition
• Pregnancy
• Pituitary, ovarian, or adrenal turners
• Depression
• Hyper thyroid or hypothermia
• Mal nutrition

13. Causes of secondary
amenorrhea
• Hyper prolactinemia
• Rapid wt gain or loss
• Chemotherapy or radiotherapy
• Vigorous excrete
• Kidney failure
• Colitis
• Tranquilizers or antidepressant
• Post partum pituitary necrosis
• Early menopause

14. Assessment:
• history of etiologic factors
• physical examination for:
1. nutritional status
2. Wt. & Ht. and vital signs
3. Anorexia nervosa( hypothermia. Bradycardia,
hypotension, and reduced subcutaneous fat)
4. Androgen excess: facial hair and acne.
5. Delayed puberty: absence of facial and axillary
hair

15. Assessment:
• laboratory tests:
1. U/S
2. Pregnancy test
3. Thyroid function test
4. Prolactine level
5. If high level of FSH: indicate ovarian failure
6. If high level of LH: indicate gonadal
dysfunction
7. Laprascopy
8. CT

16. Treatment: depend on the cause
In primary amenorrhea:
• correct the underlying cause
• estrogen replacement therapy
• if pituitary tumor: treatement with surgical resection,
radiation and drug therapy
• surgery to correct abnormalities of genital tract

17. Therapeutic intervention for
secondary amenorrhea:
Therapeutic intervention for secondary amenorrhea:
• Cyclic progesterone
• Promocriptine to treat hyperprolactinemia
• GnRH. When the cause is hypothalamic failure
• thyroid hormone replacement

18. Teaching guidelines for maintaining
healthy life style:
• balance energy expenditure with energy intake
• modify diet to maintain ideal Wt
• avoid excessive use of alcohol and mood-altering
or sedative drugs
• Avid cigarette smoking
• Identify areas emotional stress and seek assistance
to resolve them
• Balance work, recreation, and rest

19. Teaching guidelines for maintaining
healthy life style:
• Maintain a positive outlook regarding the
diagnosis and prognosis
• Participate in ongoing care to monitor
replacement therapy or associated conditions.
• Maintain bone density through:
o calcium intake( 1,200-1.5 mg or more daily)
o weight-bearing exercise(30 minutes or more daily)
o hormone replacement therapy

20. Dysmenorrhea
Etiology:
• Primary dysmenorrhea: caused by increased
prostaglandin production by the endometrium in an
ovulatory cycle which cause contraction of the
uterus. The highest level is in the first 2 days of
menses.
• Secondary dysmenorrhea: is painful menstruation
due to pelvic or uterine pathology.

21. Causes of Secondary
dysmenorrhea
• Endometriosis: ectopic implantation of the
endometrial tissue in other parts of the pelvic, it’s
the most common cause of dysmenorrhea
• Adenomiosis: ingrowth of the endometrium into
the uterine musculature.
• Fibroids
• Pelvic infection
• Intrauterine device
• Cervical stenosis
• Congenital uterine or vaginal abnormalities

22. Clinical manifestation
• sharp, intermittent spasm, usually in subrapupic area.
• pain may radiate to the back of the leg or the lower
back
• systemic symptoms:
1. nausea
2. vomiting
3. diarrhea
4. fatigue
5. fever
6. Headache or dizziness

23. Assessment:
• Focused history and physical examination:
1. in primary dysmenorrhea: cramping pain with
menstruation and the physical examination is
completely normal
2. in secondary dysmenorrhea: the history
discloses cramping pain starting after 25 years
old with pelvic abnormality.
o history of infertility
o heavy menstrual flow
o irregular cycles
o little or no response to NSAIDs

24. Assessment:
3. detailed sexual history to asses for inflammation or
scaring
4. bimanual pelvic examination in nonmenstrual phase of
the cycle
5. laboratory tests for:
 CBC to R/O anemia
 Urine analysis to R/O bladder infection
 Pregnancy test
 Cervical culture to exclude STI
 ESR to detect an inflammatory process
 Pelvic and vaginal U/S
 Diagnostic laprascopy or lapratomy

25. Treatement:
• pain relief : NSAIDs, cyclooxygenase- 2 inhibitor
• hormonal contraceptives
• life style changes:
• daily ex.
• limit salty foods
• wt. loss
• smoking cessation
• rekaxation techniques

26. Dysfunctional uterine bleeding
• is irregular, abnormal bleeding that is not caused by
pregnancy, a tumor or infection
( Bardeley, 2005).
It occurs frequently at the beginning of and end of their
reproductive years.
With anovulation, estrogen levels rise as usual in the early
phase of the menstrual cycle. In absence of ovulation, a
corpus luteum never forms and progesterone in not
produced. The endometrium moves into a hyperproliferative
state, this lead to irregular sloughing of the endometrium
and excessive bleeding.

28. Types of uterine bleeding
disorders
• Amenorrhea: (absence of menstruation)
• Hypomenorrhea: (scanty menstruation)
• Oligomenorrhea: (infrequent menstruation,
periods more than 35 days apart),
Menorrhagia: (excessive menstruation),
• Metrorrhagia: (bleeding between periods).
• Menometrorrhagia: (is heavy bleeding during
and between menstrual periods).

29. Etiology:
• adenomiosis
• pregnancy
• hormonal imbalance
• fibroid tumors
• endometrial polyps or cancer
• Endometriosis

30. Etiology:
• IUCD
• Polysystic ovary syndrome
• Morbid obesity
• Steroid therapy
• Hypothyroidism
• Clotting disorders

31. Clinical manifestation:
• vaginal bleeding between periods
• irregular menstrual cycle
• infertility
• mood swings
• hot flashes
• vaginal tenderness
• menstrual flow either scanty or profuse
• obesity
• acne
• diabetes: insulin resistance is common

32. Assessment:
• history taking
• assist in pelvic examination to identify any structural
abnormalities
• laboratory tests:
1. CBC to reveal anemia
2. PT to detect blood disorders
3. BHCG to rule out abortion or ectopic pregnancy
4. TSH to screens for hypothyroidism
• Transvaginal ultrasound to measure endometrium
• Pelvic ultrasound
• Endometrial biopsy to check intrauterine pathology
• D&C for diagnostic evaluation

33. Treatment:
it depend on the cause and age of the client
• medical care with pharmacotherapy:
1. estrogen: cause vasospasm of the uterine
arteries to decrease bleeding
2. cyclic progesterone or long acting progesterone
3. oral contraceptives: regulate the cycle and
suppress the endometrium
4. NSAIDs inhibit prostaglandin
5. Iron replacement

34. Treatment:
• if the client doesn’t respond to medical therapy:
1. D&C
2. Endometrial ablation: is an alternative to hysterectomy
3. Thermal balloon to ablate the endometrium

35. Premenstrual syndrome ( PMS)
• The premenstrual syndrome (PMS) is a distinct
clinical entity characterized by a cluster of physical
and psychological symptoms limited to 3 to 14 days
preceding menstruation and relieved by onset of the
menses.
• The incidence of PMS seems to increase with age. It
is less common in women in their teens and 20s,
and most of the women seeking help for the
problem are in their mid-30s.
• Although the causes of PMS are poorly
documented, they probably are multifactorial.

36. Clinical manifestation:
• The physical symptoms of PMS include:
o Painful and swollen breasts
o Bloating, abdominal pain
o Headache
o Backache
• Psychologically, there may be:
o Depression
o Anxiety
o Irritability
o Behavioral changes.

37. Premenstrual dysphoric disorder:
• Is a psychiatric diagnosis that has been developed to
distinguish women whose symptoms are severe enough
to interfere significantly with activities of daily living or in
whom the symptoms are not relieved with the onset of
menstruation, as is usually the case with PMS.

39. ASSESSMENT:
• Diagnosis focuses on identification of the symptom
clusters by means of prospective charting for at least 3
months.
• A complete history and physical examination are
necessary to exclude other physical causes of the
symptoms.
• Depending on the symptom pattern, blood studies,
including:
Thyroid hormones
Glucose tests may be done.
• Psychosocial evaluation is helpful to exclude emotional
illness that is merely exacerbated premenstrually.

40. TREATMENT:
• Lifestyle changes:
o An integrated program of regular exercise 3-5 times
each week.
o Reduce stress
o avoidance of caffeine
o A diet emphasizing complex carbohydrates and
increase water intake. Foods high in simple sugars
should be avoided
o Limit intake of alcohol.
o Stop smoking

41. TREATMENT:
• Vitamins and mineral supplements:
1. Multivitamin daily
2. Vitamin E,400units daily
3. Calcium, 1,200mg daily
4. Magnesium, 200-400mg daily

42. TREATMENT:
Drug therapy should be used cautiously:
1. NSAIDs taken a week prior to menses
2. Oral contraceptives ( low doses)
3. Antidepressants
4. Anxiolytics
5. Diuretics

43. Thanks!