MENSTRUAL CYCLE & MENSTRUAL DISORDER

 MENSTRUAL CYCLE & MENSTRUAL DISORDER

Menstruation is the discharge of blood and mucosal tissue from the inner lining of the uterus occurring regularly in females through the vagina after every 26-30 days throughout the reproductive age (13-45 years). Usually its duration is 3-5 days.

First menstruation in a female is known as menarche. It begins between the age of 11-15 years. 

Cessation of menstruation spontaneously at the age of 45-55 years is known as menopause.

Following two hormones play an important role in the process of menstruation-

(a) Follicle Stimulating Hormone (FSH) - It is secreted by anterior pituitary gland. It is helpful in the maturation of ovarian follicles and secretion of hormone, oestrogen.

(b) Luteinizing Hormone  (LH ) - It is also secreted by anterior pituitary gland and it is helpful in the development of corpus luteum.

Stages of Menstrual Cycle  :- 

There are four stages of Menstrual Cycle-

1. Proliferative phase

2. Secretory phase 

3. Premenstrual phase

4. Menstrual phase

Menstrual disorders :-

In this chapter, following menstrual disorders are being described-

1.Premenstrual syndrome

2. Dysmenorrheoa

3. Cryptomenorrhoea

4 Dysfunctional Uterine Bleeding (DUB) 

1. Premenstrual syndrome

*  It is also known as premenstrual tension. 

*  It is a psychosomatic disorder which occurred 7-10 days prior to menstruation.

* During this, certain behavioural, physical and emotional features are found in a woman.

* It is found in about 90% of menstruating women. Although more common in middle aged women.

* The symptoms of premenstrual syndrome resolve spontaneously after menses.

Causes :-

Exact causes are unknown. Some of possible causes are as follows :- 

# Alteration in oestrogen progesterone ratio during luteal phase.

#  Increased carbohydrate intolerance in the

luteal phase. 

# Decreased serotonin synthesis during luteal phase.

# Pyridoxine deficiency. 

# Psychologal factors.

 Clinical features :-

• Headache
• Abdominal cramps
• Breast pain
• Back ache, generalized body pain
• Insomnia
• Irritabitly
• Lack of concentration
• Anxiety Nausea
• Dizziness
• Happen
• Fainting attacks - 
• Swelling of the extremities
• Dyspareunia etc.

Treatment :-

# Reassure the woman and provide emotional support.

# Encourage family members to stay with her all time atleast any one of them.

# Administer supplementary vitamin- B6 (Pyridoxine).

#  Alprazolam 0.25mg bd during the luteal phase reduces associated anxiety and depressive features.

# Administer bromocriptine to relieve breast problems.

2. Dysmenorrhea :- 

Painful menstruation is known as dysmenorrhoea.

Types - It is of two types -

(A) Primary dysmenorrhoea

(B) Secondary dysmenorrhoea

(A) Primary dysmenorrhoea :- 

It occurs without any identifiable pathology. In other words we can say it is not associated with any other disease.

Causes :- 

Although in case of primary dysmenorrheoa. exact cause is unknown. However some of possible causes/related factors may be-

#  Septate or bicornuate uterus.

#  Uterine hypoplasia Cervical stenosis

# Increased secretion of vasopressin during menstruation

#  Increased synthesis of prostaglandins

 #  Psychological factors such as anxiety, tension etc.

Clinical features :- 

# Pain in lower abdomen, back or thighs. It usually starts few hours before the menstruation or with the starting of menstrual bleeding. The severity of pain may range from the mild to severe.

# Other associated symptoms are - nausea, vomiting, dizziness, restlessness, fatigue, headache, diarrhoea, pain in lower back etc.

Treatment :-

☆ Reassure the woman and provide emotional support.

☆ Administer mild analgesics antispasmodics during menses.

☆In severe cases, following drugs are prescribed-

(a) Prostaglandin synthetase inhibitors such as- ‎¤‫܀Mefanamic acid 

¤ Ibuprofen

(b) Oral contraceptive pills :-

• Surgical treatment - It depends upon presence of related factors such as in case of cervical stenosis, dilatation of the cervical canal is done.

• In case of elderly patient, hysterectomy may be done if other measures remain fail.

(B) Secondary dysmenorrhoea

When dysmenorrhoea occurs due to any known pelvic pathology such as any disorder in the woman's reproductive oragns or infection, then it is known as secondary dysmenorrhoea.

Causes :-

• Endometriosis.
• Adenomyosis
• Pelvic inflammatory disease
• Uterine fibroid
• Presence of Intra Uterine Contraceptive Device such as Copper-T

Clinical features :- 

● Pain in the back and front. Pain usually starts 3-5 days prior to menstruation and relieves with the onset of menses.

●Other associated symptoms like in primary dysmenorrheoa are usually absent.

Treatment :-

●Treatment of the woman depends upon causative factor, and woman's age and parity.

● For example if the problem is severe and the woman has completed her family then hysterectomy may be done.

3. Cryptomenorrhoea 

It is an abnormal condition in which periodic shedding of the endometrium and bleeding occure but the blood does not come out through the vagina It means during this condition menstruation occures but is not visible. 

Causes :-

Usually any obstruction in the pessage is its main cause. Its causes are -

● Imperforate hymen (It is the commonest cause).

● Vaginal or cervical atresia

● Transverse vaginal septum 

● Cervical stenosis after cervical amputation or canisation.

●Secondary vaginal atresia after complicated vaginal delivery.

Clinical features :-

● Menstrual blood does not come out. 

● Cyclic lower abdominal pain. 

Signs :-

● Haematocolpos - Retension of menstrual blood in the vagina.

● Enlarged uterus.

● Haematometra - Accumulation of blood in the uterine cavity.

● Bulging hymen.

Management :-

◇ First of all patient's diagnosis is confirmed based upon clinical manifestations and various examination.

◇Management of cryptomerrheoa mainly depend upon its cause for example.

◇   If cause is imperforate hymen then simple

cruciate incision of the hymen is made.

◇ In case of cervical stenosis, cervical dilatation is done.

4. Dysfunctional Uterine Bleeding 

◇  It is abbreviated as DUB

◇Abnormal uterine bleeding which is not associated with any genital tract abnormalities and general or endocrinologial disorders.

◇ This condition is more common after delivery and abortion.

◇ It is found in about 10-15% of reproductive aged women, 

Possible causes :- 

* Fibroids

* Uterine polyps Adenomyosis Blood clotting disorders

* Problems with ovulation etc.

Clinical features :- 

● Abnormal vaginal bleeding is the main clinical feature found in the woman.

Investigations :- 

• History taking
• Bimanual examination 
• Blood examinations such as :- 
• Haemoglobin level 
• Bleeding Time
• Clotting Time
• Prothrombin Time
• platelet count
• Thyroid profile
• Ultrasonography
• Diagnostic uterine curettage
• Diagnostic hysteroscopy Diagnostic laparoscopy
• Hysterography

Management :-

●  Reassure the woman and provide emotional support to reduce her anxiety and fear .

●  Encourage the woman to take adequate bed rest during bleeding.

Pharmacological management :- 

Following drugs are used -

(A) Hormones

●  Oral contraceptive pills containing progesterone and oestrogen 

●  Norethisterone acetate

●  Medoxy progesterone acetate 

●  Danazol

●  GnRH analgues

●  Clomiphene citrate

(B) Antifibrinolytic agents

● Tranexamic acid

Surgical management

■  Uterine curettage

■  Endometrial ablation

■  Bilateral uterine artery embolization

■  Hysterectomy (Surgical removal of the uterus)

5. Menorrhagia

Abnormally heavy or prolonged (or both) menstrual bleeding, is known as menorrhagia.

Causes :-

1. General causes

• Blood dyscrasia
• Hypo or hypethyroidism
• Coagulopathy
• Severe hypertension
• Genital TB

2. Pelvic causes

• Pelvic inflammatory diseases
• Uterine fibroids
• Adenomyosis
• Endometriosis
• Tubercular endometritis Pelvic congestion
• Chronic tubo-ovarian mass

3. Contraceptive use

•  IUCD
• Progestogen oral pill

Treatment :-

Treatment of the patient is mainly based upon its causative factor. On the basis of cause. usually following treatment modalities are used as per need -

● Non-Steroidal Anti Inflammatory Drugs such as Ibuprofen.

● Oral contraceptive pills containing oestrogen and progesterone.

● Tranexamic acid.

Surgical procedures such as - 

• Dilatation and Curettage
• Uterine artery embolization
• Myomectomy
• Endometrial resection
• Hysterectomy

BY :- A. Kumar 

Bibliography :- 

Midwifery for Nurses 

Section:-  B 

Gynecology 

Unit :- 2 

Chapter :- 4 

Page :- 658 - 662 

Author :- 

Dr. Preeti Agarwal & Vinod Gupta