DISORDERS OF MENSTRUATION

A. Amenorrhoea (Absence of Menstruation)

This is the absence of menstruation and is graded by type.

1. Apparent Amenorrhoea (Cryptomenorrhoea): This occurs when the period contents are produced but not expelled due to an obstruction, such as an imperforated hymen.

2. Primary Amenorrhoea: Menstruation has never occurred. A gynecological consultation is advised if periods have not started by age 17.

• Causes:

  • Congenital Abnormalities: Malformation of the uterus, vagina, or ovaries.

  • Hormonal Imbalance/Dysfunction: Mal-developed or dysfunctional Anterior Pituitary Gland (Hypopituitarism) or issues with the thyroid/adrenal glands.

  • Serious Illness.

  • Note: Primary amenorrhoea is often due to a permanent defect of the ovaries.

3. Secondary Amenorrhoea: Menstruation ceases after it had been established for months or years.

• Causes:

  • Pregnancy: The most common cause if fertilization has occurred.

  • Emotional/Psychological: Excitement, worry, fear, or change of environment.

  • Glandular Dysfunction: May be associated with over-secretion of the thyroid gland or Adrenaline.

  • Hormonal/Medication: Contraceptive pills (use of Progesterone and Oestrogen).

  • Lactation: If it is full-time breastfeeding.

  • Infection/Systemic Illness: Pulmonary tuberculosis, severe Inflammatory diseases of the pelvis, severe Anemia, HIV infection, or malnutrition.

  • Menopause.

B. Dysmenorrhoea (Painful Periods)

Painful menstruation, usually of uterine origin, which can be severe enough to require bed rest. The pain is often colicky due to uterine muscle contractions, lasting for the first 12 hours of menses. It can sometimes be accompanied by nausea, vomiting, or diarrhea.

1. Primary Dysmenorrhoea (Spasmodic): Pain is directly due to the mechanism of menstruation itself.

• Causes:

  • Obstruction: Narrow cervical os or malposition of the uterus.

  • Vaso-constriction: Vaso-constriction of terminal arteries leading to Ischemia, causing spasms and uterine pain.

  • Hypomenorrhoea: Associated with clots in the cervical os that must be expelled.

2. Secondary Dysmenorrhoea (Congestive): Pain develops after menstruation has been established for many years (usually after age 30) and is often associated with inflammation or other pelvic conditions.

• Causes: Pelvic congestion brought about by infections, inflammation of the pelvic organs, retroversion of the uterus, fibroids, or cancer. Psychological factors like anxiety, emotional upset, or domestic problems may also contribute.

3. Membranous Dysmenorrhoea: The whole part of the Endometrium is shed in one piece, which is very painful to expel.

• Causes: Due to dysfunction of the Anterior Pituitary Gland (A.P.G).

Management: Management should start with non-pharmacological methods:

• Placing warm compress on the lower abdomen.

• Waist massage.

• Keeping busy and taking warm water.

If this fails, pharmacological therapy with NSAIDS can be initiated (e.g., Ibuprofen $400\text{m}g$ or Mefenamic acid $500\text{m}g$ every 8 hours for 3 days). In rare cases, cervical dilation may provide a permanent cure.

C. Other Frequency and Volume Disorders

1. Scanty Frequent Menstruation (Hypomenorrhoea): Common and often clears up after treatment.

• Causes: Before menopausal age, causes include emotional upset, illness, and hormonal imbalance.

2. Menorrhagia (Too Frequent/Excessive Bleeding): Too frequent bleeding, excessive bleeding at the time of the period, or both. This is a symptom, not a disease.

• Causes:

  • Uterine/Cervical Issues: Fibroids, Endometritis, Endometrium/cervical polyps, Cervical erosions, or Carcinoma.

  • Hormonal/Glandular: Disturbances due to emotional upset, hormonal imbalance (usually excessive Oestrogen), Ovarian bleeding, or Thyroid dysfunction (e.g., Myxoedema).

  • Systemic: Anemia, Blood disorders.

3. Oligomenorrhoea (Infrequent Periods): Low intervals between periods, which occur only 2 or 3 times a year.

4. Metrorrhagia (Intra-Menstrual Bleeding): Bleeding that occurs between periods.

• Causes: Cervical erosion, Fibroids, Polyps, Carcinoma, or Ovarian issues.