Introduction to Menstrual Disorders

Menstrual disorders encompass a range of abnormalities in a woman’s menstruation during her reproductive years. These irregularities can significantly impact a woman’s health and quality of life. Common menstrual disorders include:

1. Amenorrhea

2. Dysmenorrhea

3. Menorrhagia

4. Metrorrhagia

5. Polymenorrhea (epimenorrhea)

6. Dysfunctional Uterine Bleeding (DUB)

7. Endometriosis

Amenorrhea: Absence of Menstruation

Amenorrhea is defined as the absence of menstruation in a woman of reproductive age. It is not a disease itself but rather a symptom of an underlying issue. It can be broadly classified into two types:

1. Primary Amenorrhea: This refers to the failure of menstruation to begin by the age of 16. It may be due to congenital abnormalities like an imperforate hymen where menstrual blood cannot exit despite a normal cycle, or other developmental issues.

2. Secondary Amenorrhea: This occurs when a woman who previously had regular menstrual periods experiences a cessation of menstruation for six months or more.

Causes of Amenorrhea

• Physiological:

  • Pregnancy: Elevated estrogen and progesterone levels maintain the uterine lining, preventing menstruation.

  • Lactation: Prolactin, a hormone produced during breastfeeding, suppresses the hormones needed for ovulation.

• Hypothalamic Dysfunction: Conditions affecting the hypothalamus, a brain region regulating hormones, can lead to low levels of FSH and LH, disrupting the menstrual cycle. Congenital syndromes can also impair hypothalamic-gonadal function.

• Pituitary Disorders: Elevated prolactin levels (hyperprolactinemia), often due to pituitary tumors, can interfere with ovulation and menstruation.

• Congenital Abnormalities: Structural issues include an imperforate hymen, vaginal septum, absence of a uterus or ovaries, cervical stenosis, and conditions like Kallmann’s syndrome (absence of hypothalamus leading to hypogonadism).

• Lifestyle Factors: Significant environmental or occupational changes, extreme stress, anxiety, or excitement can disrupt the hormonal balance.

• Psychological Factors: Pseudoamenorrhea is a psychological condition where a woman mistakenly believes she’s pregnant, causing the cessation of her periods.

• Medical Procedures: Hysterectomy, bilateral removal of ovaries, full radiation doses or certain medications (hormonal contraceptives) can cause amenorrhea.

• Debilitating Diseases: Conditions like tuberculosis, HIV/AIDS, and diabetes can contribute to the lack of menstruation.

• Tumors: Tumors of the pituitary gland, hypothalamus, ovaries, or uterus can disrupt hormonal regulation.

• Early Menopause: Premature ovarian failure leads to the cessation of menstrual cycles.

• Idiopathic: In some cases, the cause of amenorrhea remains unknown.

Diagnosis and Investigations

• Detailed History and Physical Examination: Gathering information about weight changes, stress levels, and physical characteristics like excessive body hair.

• Urine HCG Test: To rule out pregnancy as a cause.

• Pelvic Ultrasound: To visualize the pelvic organs and detect structural abnormalities.

• Blood Hormone Analysis: To assess hormone levels (FSH, LH, prolactin, estrogen, progesterone).

• Computerized Tomography (CT) Scans: For further visualization of organs and potential abnormalities.

Management of Amenorrhea

The approach to treatment depends on the underlying cause, and may involve medical, surgical or psychological interventions

• Nursing Management:

  • Comprehensive assessment of medical and menstrual history and physical examination.

  • Providing emotional support and addressing emotional distress.

  • Education on menstrual health, reproductive anatomy, and treatment options.

  • Promoting a healthy lifestyle including exercise, nutrition, and stress management.

  • Counseling on contraception and family planning.

• Medical Management:

  • Hormone Therapy: To address hormonal imbalances related to conditions like PCOS or hypothalamic dysfunction.

  • Medications: Progestins or combined oral contraceptives can induce menstruation or regulate menstrual cycles.

  • Treatment of Underlying Conditions: Managing thyroid disorders or pituitary tumors.

  • Hyperprolactinemia Treatment: Bromocriptine is used to inhibit prolactin secretion. Radiotherapy may be considered if medication is ineffective.

• Surgical Management:

  • Rarely required but necessary to address structural abnormalities.

  • Hysteroscopic Surgery: To treat uterine polyps or adhesions.

  • Imperforate Hymen Correction: Incision and drainage of an imperforate hymen with plastic surgery if needed.

  • Surgical Intervention: Correction of reproductive organ abnormalities, tumor or cyst removal.

• Psychological Management:

  • Counseling and support to address emotional distress related to amenorrhea.

  • Support group participation and connection with other women.

  • Promoting a positive body image and self esteem.

Dysmenorrhea: Painful Menstruation

Dysmenorrhea refers to painful menstrual periods, commonly known as menstrual cramps. About half of all women experience some degree of pain with their periods, with about 10% experiencing pain severe enough to impact their daily activities.

Types, Causes, and Symptoms of Dysmenorrhea

Causes of Dysmenorrhea

• The exact cause of Primary Dysmenorrhea isn’t fully understood, but is linked to prostaglandins released from the uterine lining that cause uterine muscle contractions.

• Secondary Dysmenorrhea is usually caused by underlying health conditions affecting the reproductive organs.

Types of Dysmenorrhea

1. Primary Dysmenorrhea: Painful menstruation without an identifiable underlying cause, usually starting a few years after puberty.

   • Predisposing factors: include a narrow cervical os, reduced blood supply to the endometrium, hormonal imbalances, a retroverted uterus, and psychological stress.

   • Signs and Symptoms: cyclic pain occurring just before or during the first few days of menstruation, lower abdominal pain (ranging from mild to severe), nausea and vomiting, constipation or diarrhea, fainting, headache, malaise, irritability, nervousness and depression.

2. Secondary Dysmenorrhea: Painful menstruation that develops later in life due to an underlying condition.

   • Causes: include Pelvic Inflammatory Disease (PID), uterine fibroids, endometriosis, and endometritis.

   • Signs and Symptoms: pain beginning 3-4 days or a week before menstruation, backache, menorrhagia, painful coitus and difficulty in conceiving

Diagnosis

• History Taking: Detailed history of pain, duration, and timing in relation to the menstrual cycle.

• Physical Examination: To rule out pelvic tumors or endometriosis.

Treatment and Nursing Management

Treatment

• Primary Dysmenorrhea:

  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Such as ibuprofen, mefenamic acid, or diclofenac, to reduce prostaglandin production.

  • Antispasmodics: Like Buscopan, to relieve muscle spasms.

  • Antiemetics: Like Phenergan to control nausea and vomiting.

  • Heat therapy: application of hot water bottles or heating pads to the abdomen.

  • Hormonal Contraceptives: Oral contraceptive pills to regulate menstrual cycles and reduce pain.

  • Mild analgesics Like Ibuprofen, prostaglandin inhibitors like Mefenamic acid and progesterones may be prescribed to ease pain.

  • Counseling: To address psychological factors and prevent drug dependence.

  • Lifestyle: Encourage rest, sleep and exercises and good hygiene.

• Secondary Dysmenorrhea:

  • Investigate and treat underlying cause.

  • Medications for pain relief and supportive measures.

Nursing Management

• Nursing Diagnoses: Acute pain, ineffective coping, and risk for imbalanced nutrition.

• Nursing Interventions:

  • Applying warmth to the abdomen, massage, light exercises and relaxation techniques.

  • Administering analgesics, assessing the patient’s understanding of the condition and help the patient identify coping mechanisms

  • Encouraging frequent small feeds and administering antiemetics.

Nursing Concerns:

• Assessing pain severity, vital signs, menstrual patterns and their impact on daily life.

• Evaluating for associated symptoms or complications like nausea, headaches or anemia.

• Providing pain management, applying heat therapy and assisting with relaxation techniques.

• Promoting rest and comfort and providing information about the condition.

• Offering emotional support, and collaborating with other members of the healthcare team

Menorrhagia, Metrorrhagia, and Polymenorrhea

Menorrhagia is characterized by abnormally heavy or prolonged menstrual bleeding.

Causes of Menorrhagia

• Hormonal Imbalances: Fluctuations in estrogen and progesterone can lead to excessive bleeding.

• Uterine Fibroids: Noncancerous growths in the uterus causing heavy bleeding.

• Adenomyosis: Endometrial tissue growing into the uterine muscle wall.

• Polyps: Small, benign growths in the uterine lining.

• Endometrial Hyperplasia: Abnormal thickening of the uterine lining.

• Inherited Bleeding Disorders: Like von Willebrand’s disease.

• Pelvic Inflammatory Disease (PID)

• Retroverted Uterus.

• Cancers: Like cervical or endometrial cancer.

Signs and Symptoms of Menorrhagia

• Menstrual bleeding lasting longer than seven days.

• Soaking through one or more sanitary pads every hour for several consecutive hours.

• Passing large blood clots.

• Fatigue and tiredness.

• Shortness of breath or rapid heart rate.

• Lightheadedness or dizziness.

• Menstrual periods that disrupt daily activities.

Investigations

• Complete medical history and physical examination.

• Blood tests to assess blood count, iron levels and hormonal imbalances.

• Transvaginal ultrasound to evaluate the structure of the uterus.

• Endometrial biopsy to examine the uterine lining.

• Hysteroscopy to directly visualize the uterine cavity.

• Bleeding, prothrombin and clotting time to check for coagulopathy

• Full Haemoglobin and hormonal analysis.

Management

• Medical Management:

  • Medications: NSAIDs to reduce pain and bleeding, hormonal contraceptives (birth control pills or IUDs) to regulate cycles and reduce bleeding.

  • Iron supplementation: to restore iron levels if anemia is present.

  • Endometrial ablation: a minimally invasive procedure that destroys the lining of the uterus.

  • Uterine artery embolization: reduces blood flow to the uterus to control bleeding.

• Nursing Management:

  • Managing symptoms, providing emotional support, education and lifestyle advice.

Nursing Diagnosis and Interventions

• Diagnosis: Ineffective tissue perfusion related to excessive bleeding.

• Interventions:

  • Assessing vital signs, elevating feet, administering intravenous fluids and vitamin K, and whole blood transfusions if prescribed.

Metrorrhagia refers to irregular or abnormal uterine bleeding that occurs between menstrual periods, or at normal intervals but excessively in amount or duration. It is a symptom of some underlying pathology.

Causes of Metrorrhagia

• Fibroid uterus.

• Adenomyosis.

• Pelvic endometriosis.

• Chronic tubo-ovarian mass.

• Retroverted uterus.

• Uterine polyp.

• Cervical erosions.

• Cancers of the cervix or endometrium.

• Chronic threatened or incomplete abortion.

• Retained pieces of placenta.

• Mole pregnancy.

• Ovulation bleeding.

• Short cycles like polymenorrhea.

Signs and Symptoms of Metrorrhagia

• Bleeding between periods.

• Irregular menstrual cycles.

• Heavier or lighter bleeding during periods.

• Prolonged bleeding.

• Pelvic pain.

• Fatigue and anemia.

Investigations

• Medical history and physical examination.

• Hormone level assessment.

• Transvaginal ultrasound.

• Endometrial biopsy.

• Hysteroscopy.

• Digital and speculum examination to visualize the cervix.

• Pelvic scan

Management

• Medical and Nursing Management:

  • Hormonal therapy to regulate menstrual cycles.

  • NSAIDs to manage pain and bleeding.

  • Treatment of underlying conditions like fibroids or infections.

  • Surgical interventions if necessary.

  • Supportive care and monitoring of the patient.

Polymenorrhea, also known as epimenorrhea, is characterized by frequent menstrual periods occurring more often than the normal menstrual cycle (less than 21 days), but regular.

Causes of Polymenorrhea

• Hormonal Imbalances: Fluctuations in estrogen and progesterone.

• Thyroid Disorders: Overactive or underactive thyroid affecting hormone levels.

• Polycystic Ovary Syndrome (PCOS): Hormonal imbalances, ovarian cysts and irregular cycles.

• Uterine Abnormalities: Fibroids, polyps or adenomyosis.

• Stress and Lifestyle Factors: Chronic stress, excessive exercise, drastic weight changes, or poor nutrition.

Signs and Symptoms

• Menstrual cycles shorter than 21 days.

• Frequent periods, every two weeks or less.

• Lighter or heavier bleeding.

• Increased discomfort or pain.

• Fatigue.

• Emotional and psychological impact.

Investigations

• Medical history and physical examination.

• Hormone level assessment.

• Pelvic ultrasound.

• Endometrial biopsy.

Management

• Medical and Nursing Management:

  • Hormonal therapy to regulate menstrual cycles and frequencies.

  • Treatment of underlying conditions like PCOS or uterine abnormalities

  • D&C to remove retained products of conception.

  • Lifestyle modifications.

  • Supportive care and monitoring of the patient.

Dysfunctional Uterine Bleeding (DUB)

Dysfunctional uterine bleeding (DUB) refers to abnormal uterine bleeding in the absence of organic or underlying medical conditions, caused by hormonal changes. It is characterized by irregular, prolonged or heavy menstrual bleeding.

Causes of DUB

• Sustained levels of estrogen leading to thickening of the endometrium which shed incompletely and irregularly.

Pathophysiology

• Local causes in the endometrium, disturbances in blood vessels and coagulation

• Alteration of prostaglandins in the endometrium

Signs and Symptoms of DUB

• Irregular menstrual cycles.

• Prolonged bleeding.

• Heavy menstrual bleeding.

• Intermenstrual bleeding.

• Fatigue.

• Symptoms of anemia.

Investigations

• Ultrasound scan to rule out growths.

• Blood analysis for hormonal imbalance.

• Biopsy for histology.

Management

• Total hysterectomy if the patient is over 35 years with thickened endometrium containing abnormal cells, and doesn’t desire to become pregnant.

• High doses of combined oral contraceptives or estrogen alone followed by progestins for women with thickened endometrium but with normal cells.

• Low doses of COCs if bleeding is lighter.

• Progestin pills for 10-14 days each month if estrogen is contraindicated.

• D&C for ineffective response or hormonal therapy.

• Clomiphene for women who desire pregnancy.

Endometriosis

Endometriosis is a chronic condition where tissue similar to the uterine lining (endometrium) grows outside the uterus.

Causes of Endometriosis

• Retrograde Menstruation: Backwards flow of menstrual blood into the tubes and pelvic cavity.

• Hormonal Imbalance: Estrogen promoting growth of misplaced tissues.

• Genetic Factors: Increased risk with family history.

• Immune System Dysfunction: A weakened immune response allowing misplaced tissue growth.

• Environmental Factors: Exposure to toxins and chemicals.

• Surgery like CS, D&C

• Late prime para

• Race- More common in Caucasians

• Retroverted uterus

Signs and Symptoms

• Asymptomatic in some cases.

• Lower abdominal pain.

• Irregular periods.

• Infertility.

• Painful coitus.

• Pain during bowel movements.

• Rectal bleeding during menstruation.

• Bleeding from site during menstruation

• Palpable mass (endometrioma)

• Adhesions.

Diagnosis/Investigations

• Biopsy confirms the diagnosis.

• Laparoscopy.

• Ultrasound scan.

• Barium enema with x-ray.

• CT scan and MRI

• Blood for marker cells (CA-125).

Management

• Nursing, Medical and Surgical Management:

  • Pain management.

  • Hormonal therapy (birth control pills, hormonal patches or progestins).

  • Drugs to suppress ovarian activity and slow growth of endometrial tissue (COCs, progestins, GnRH agonists).

  • Surgical intervention (laparoscopic surgery).

  • Combination of drugs and surgery or Total hysterectomy if other treatments fail.

  • Fertility treatments.

  • Supportive care and education.

Complications

• Infertility.

• Ovarian cysts (endometriomas).

• Adhesions.

• Chronic pain.