Govt.

College Of Nursing Ahmedabad

SUBJECT : TOPIC : DATE
:
obstetric and gynecological nursing-II presentation on menstrual irregularities / /2011

SUBMITTED TO:Mrs. Hiral r. shah Lecturer sr. scale class-I Govt. College Of Nursing Ahmedabad.

SUBMIITTED BY:Mistri kinjal s. s.Y. M.Sc. Nursing govt.College of Nursing Ahmedabad.

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Menstrual irregularities
Introduction: Menstrual irregularities are common abnormalities of a womans menstrual cycle. Menstrual irregularities include a variety of conditions in which menstruation is irregular, heavy, painful, or does not occur at all. Types of menstrual irregularities: Common types of menstrual irregularities include: Amenorrhea (when a teenager does not get her period by age 16, or when a woman stops getting her period for at least three months and is not pregnant) Dysmenorrhea (painful menstrual periods) Menorrhagia (heavy menstrual periods) Oligomenorrhea (menstrual bleeding occurring more than 35 days after the last menstrual period, that is, less than 10 periods a year) Polymenorrhea (menstrual bleeding occurring less than 21 days after the last menstrual period, that is, more than 12 periods a year) Spotting (light irregular vaginal bleeding or vaginal bleeding between periods)

Causes of menstrual irregularities: Menstrual irregularities can be associated with normal conditions, such as puberty or ovulation. Your menstrual period may last for just a few days or for more than a week. A normal menstrual flow can differ greatly from woman to woman and also varies in different phases of life, such as adolescence and perimenopause. Potential causes of menstrual irregularities Menstrual irregularities can be caused by a variety of underlying factors, causes of menstrual irregularities include: Extremely low levels of body fat, which can be caused by malnourishment, extreme physical training, or eating disorders Endometriosis Obesity Ovulation Perimenopause and menopause Polycystic ovary syndrome Pregnancy Puberty Sexually transmitted diseases (STDs) and pelvic inflammatory disease (PID) Side effect of certain medications, such as birth control pills Stress Uterine fibroids or uterine polyps

Uterine, vaginal, cervical or ovarian cancer

What other symptoms might occur with menstrual irregularities? Menstrual irregularities may occur with other symptoms depending on the underlying disease, disorder or condition. For example, menstrual irregularities due to a pelvic infection may be associated with fever and painful sexual intercourse. Symptoms that may occur along with menstrual irregularities Menstrual irregularities may accompany other symptoms including: Burning with urination Difficulty getting pregnant or infertility Fever Lower back pain Nausea and vomiting Painful bowel movements Painful sexual intercourse Pelvic or abdominal pain or cramps Symptoms of perimenopause or menopause, such as hot flashes, headaches, mood swings, heart palpitations, forgetfulness, and sleeping problems Unusual vaginal discharge Symptoms that might indicate a serious or life-threatening condition: In some cases, menstrual irregularities can be caused by a serious or lifethreatening condition, such as anemia, pelvic inflammatory disease, or uterine cancer. Seek prompt medical care if you, or someone you are with, have any of the following symptoms: Pelvic or abdominal pain Periods that are heavier or longer than usual Unusual vaginal bleeding Vaginal bleeding after menopause What are the potential complications of menstrual irregularities? In some cases, menstrual irregularities can be due to a condition that can result in serious or life-threatening complications. Complications of menstrual irregularities and underlying causes can include: Anemia, due to excessive blood loss Chronic pelvic pain Difficulty getting pregnant and infertility
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Ectopic pregnancy Metastatic cancer that can become terminal Pelvic adhesions and scarring of the fallopian tubes Severe hemorrhage

Amenorrhea
Amenorrhea is the absence of a menstrual period. Amenorrhea can be classified as primary or secondary. Primary amenorrhea is when a young woman has not yet had a period by age 16. Secondary amenorrhea describes someone who used to have a regular period but then it stopped for at least three months (this can include pregnancy). Amenorrhea is a symptom of a variety of conditions, ranging from not serious to serious.

Causes of amenorrhea: Primary Amenorrhea Chromosomal or genetic abnormalities like Gonadal dysgenesis is the name of a condition in which the ovaries are prematurely depleted of follicles and oocytes (egg cells) leading to premature failure of the ovaries. It is one of the most common cases of primary amenorrhea in young women. Turner syndrome, in which women are lacking all or part of one of the two X chromosomes normally present in the female. In Turner syndrome, the ovaries are replaced by scar tissue and estrogen production is minimal, resulting in amenorrhea. Estrogen-induced maturation of the external female genitalia and sex characteristics also fails to occur in Turner syndrome. Hyperprolactinemia Hypothyroidism and hyperthyroidism Obesity Hypogonadotropic hypogonadism Cystic fibrosis Hypothalamic or pituitary diseases and physical problems, such as problems with reproductive organs, can prevent periods from starting. Moderate or excessive exercise, eating disorders (such as anorexia nervosa), extreme physical or psychological stress, or a combination of these can disrupt the normal menstrual cycle. Tumors of the pituitary or adrenal glands Tumors of the ovaries

Secondary amenorrhea This problem is much more common than primary amenorrhea.

Common causes include many of those listed for primary amenorrhea, as well as pregnancy, certain contraceptives, breastfeeding, mental stress, and certain medications. Tumors or other diseases of the pituitary gland that lead to elevated levels of the hormone prolactin (which is involved in milk production) also cause amenorrhea due to the elevated prolactin levels hypothyroidism elevated levels of androgens (male hormones), either from outside sources or from disorders that cause the body to produce too high levels of male hormones ovarian failure (premature ovarian failure or early menopause) polycystic ovary syndrome Asherman's syndrome is an example of uterine disease that causes amenorrhea. It results from scarring of the uterine lining following instrumentation (such as dilation and curettage) of the uterine cavity to manage postpartum bleeding or infection. Women who have very low body weight sometimes stop getting their periods as well. Women with premature ovarian failure stop getting regular their periods before natural menopause.

Symptoms of amenorrhea: A female with amenorrhea will have no menstrual flow with or without other signs of puberty. Primary or secondary amenorrhea (respectively) is considered to be present when a girl has: Not developed menstrual periods by age 16; or A woman who has previously had a menstrual cycle stops having menstrual periods for three cycles in a row, or for a time period of six months or more and is not pregnant. Other symptoms and signs may be present, which are highly variable and depend upon the underlying cause of the amenorrhea. For example, symptoms of hormonal imbalance or male hormone excess can include irregular menstrual periods, unwanted hair growth, deepening of the voice, and acne. Elevated prolactin levels as a cause of amenorrhea can result in galactorrhea (a milky discharge from the nipples that is not related to normal breastfeeding). Investigation: The doctor will perform a physical exam and ask questions about your medical history. A pregnancy test will be done. Depending upon the results of the history and physical examination further diagnostic tests may be ordered. In primary amenorrhea with female external genitalia:

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Investigate At 16 Completed Year, History &Clinical Examionation

Breast Not Developed

Breast Developed

Laproscopy, Gonadal Biopsy, Karyotyping

Endometrial Pitutiary And Evaluation

Biopsy, Endocrine

Uterus Present -Gonadal Failure: Turner's Syndrome Pure Gonadal Agenesis (46XX, 46XY) --CNS Hypothalamus Pitutiary Disorders: CNS Lesion Hypothalamic Failure Blood tests may include: Estradiol FSH LH Prolactin TSH T3 and T4

Uterus Absent --Agonadism --17,20 desmolase deficiency

Uterus Present -Hypothalamic Cause --Pituitary Cause --Ovarian Cause (PCOD) --Uterine (TB)

Uterus Absent --Uterovaginal Atresia --Testicular Feminisation Syndrome

 In secondary amenorrhea: Step-1: Progesterone challenge test (PCT)

Uterine bleeding (Positive response) Step-2: PCT Positive Response, uterine bleeding Serum LH, Prolactin

no uterine bleeding (Negative response)

LH high (>25mIU/ml) LH/FSH>3 Policystic overy disease DHEAS If high induce uterine bleeding every month by progesterone oral contraceptive dexamethasone

LH normal

hypothalamic dysfunction, Drugs, stress, exersice, wt loss

prolactin normal induce monthly bleeding every month by progesterone

prolactin high TSH for hypothyrodism CT Scan for pitutiary microadenoma

Step-3: PCT negative Response, no uterine bleeding FSH

Normal synechia uterine TB

low

elevated (>30mIU/ml) premature ovarian failure. Premature menopause

Hypothalamus pituitary failure prolactin high, CT Scan pitutiary microadenoma, macroadenoma

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 Other tests that may be done include: 17 hydroxyprogesterone Chromosome analysis Head CT Head MRI scan Laparoscopy Pelvic ultrasound Progesterone withdrawal Serum progresterone Treatment: Treatment depends on the cause of the missing period. Primary amenorrhea caused by genetic or anatomical abnormalities/ birth defects may require medications (hormones), surgery, or both. If the amenorrhea is caused by a tumor in the brain (pituitary tumor):

Medications may shrink certain types of tumors. Surgery to remove the tumor may also be necessary. Radiation therapy is usually only performed when other treatments have not worked.

Hypothalamic amenorrhea that is related to weight loss, excessive exercise, physical illness, or emotional stress can typically be corrected by addressing the underlying cause. For example, weight gain and reduction in intensity of exercise can usually restore menstrual periods in women who have developed amenorrhea due to weight loss or overly intensive exercise, respectively, who do not have additional causes of amenorrhea. In some cases, nutritional counseling may be of benefit. In premature ovarian failure, hormone therapy may be recommended both to avoid the unpleasant symptoms of estrogen depletion as well as prevent complications of low estrogen level such as osteoporosis. This may consist of oral contraceptive pills for those women who do not desire pregnancy or alternative estrogen and progesterone medications. While postmenopausal hormone therapy has been associated with certain health risks in older women, younger women with premature ovarian failure can benefit from this therapy to prevent bone loss. Women with PCOS (polycystic ovary syndrome) may benefit from treatments that reduce the level or activity of male hormones, or androgens.

Dopamine agonist medications such as bromocriptine (Parlodel) can reduce elevated prolactin levels, which may be responsible for amenorrhea. Consequently, medication levels may be adjusted by the person's physician if appropriate. Prognosis: Overall the outlook is good, depending on the cause of the amenorrhea. If the amenorrhea is caused by one of the following conditions, there is a good chance that it can be corrected with medication, lifestyle changes, or surgery:

Adrenogenital syndrome Chronic illness Congenital heart disease Drastic weight reduction Hypogonadotropic hypogonadism Imperforate hymen or vaginal septum Malnutrition Normal delay of onset (up to age 14 or 15) Obesity Overactive thyroid

Periods are unlikely to start on their own if the amenorrhea was caused by one of the following conditions:

Congenital abnormalities of the upper genital system Craniopharyngioma Cystic fibrosis Gonadal dysgenesis Prader-Willi syndrome Testicular feminization syndrome True hermaphroditism Turner syndrome (XO)

If the amenorrhea cannot be corrected, it is sometimes possible to create a menstruallike situation (pseudomenstruation) with medications. Medicines can help you feel more like your friends or family, and will also protect the bones from becoming too thin (osteoporosis). Complication: Infertility Emotional distress due to feeling different from friends or family, or worrying you might not be able to have children Osteoporosis and increased risk of fractures
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Oligomenorrhea
This is defined as the occurance of menses on only five or fewer occasion in a year. The causes and management are same as secondary amenorrhea.

Dysmenorrhea
Definition: It means painful menstruation incapacitating the woman. Types: Spasmodic / primary dysmenorrhea signifies the pain due to menstruation and of uterine origin, no obvious pelvic lesion found to cause the pain. Congestive / secondary dysmenorrhea means pain associated with menstruation is related to pelvic lesion. E.g. endometriosis, chronic pelvic inflammatory disease, IUCD, uterine fibroid Clinical features: Sr.n Primary dysmenorrhea o. Symptoms Patient is young, usually 18-24 1. years, rare after 30yrs. Painful means usually occurs 2. years after menarche. Pain start 1-2 hrs before onset of 3. menses usually continues for the first 12-24hrs and then gradually gets less. Pain is colicky, cramp like occurs 4. in hypo gastric region and radiates to the thighs. There may be low backache. The inter menstrual period is free 5. from the pain. 6.

Secondary dysmenorrhea

Patient usually elderly beyond 30yrs. Painful means occurs after a period of painless menstruation Pain starts 3-5days before the onset of menses after that pain usually get less Pain is dull ache in the back or lower abdomen without any radiation.

The inter menstrual period may have backache and lower abdominal discomfort. Other symptoms like nausea, Other symptoms like whit vomiting, diarrhea due to discharge, menorrhegia, infertility

prostaglandin effect or fainting may etc. be present. Signs 1 2 3 Patient may be poor state of Patient is healthy except being health and anxious. slightly aneamic. Per abdomen nothing abnormal is Primary lesion felt like uterine detected. fibroid. Per vaginal- uterus felt usually There is any type of pelvic normal. pathology in uterus.

Causes: In primary dysmenorrhea: 1. Obstructive factor 2. Hypoplastic factor 3. Muscle ischemic factor 4. Neurogenic factor 5. Psychological and social factor 6. Endocrine factor 7. prostaglandin In secondary dysmenorrhea: 1. Uterine condition 2. Pelvic inflammatory condition 3. Pelvic endometriosis Investigation: The diagnosis of dysmenorrhea is usually made by the woman herself and reflects her individual perception of pain. Once a woman has experienced dysmenorrhea, usually with the adolescent onset of her monthly menstrual flow (menses), she becomes well aware of the typical symptoms. If there are other medical conditions contributing to dysmenorrhea (secondary dysmenorrhea), the doctor may suggest diagnostic testing including imaging studies. Treatment of primary dysmenorrhea: Prevention: proper sex education to the girls starting menarche is important. Curative: Medical treatment Every woman needs to find a treatment that works for her. There are a number of possible remedies for dysmenorrhea. Current recommendations include not only adequate rest and sleep, but also regular exercise (especially walking). Some women find that abdominal massage, yoga, or orgasmic sexual activity may bring relief. A heating pad applied
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to the abdominal area may relieve the pain and congestion and decrease symptoms. For mild cramps, aspirin or acetaminophen (Tylenol), or acetaminophen plus a diuretic (Diurex MPR, FEM-1, Midol, Pamprin, Premsyn, and others) may be sufficient. However, aspirin has limited effect in curbing the production of prostaglandin and is only useful for less painful cramps. The main agents for treating moderate dysmenorrhea are the nonsteroidal antiinflammatory drugs (NSAIDs), which lower the production of prostaglandin and lessen its effect. The NSAIDs that do not require a prescription are:ibuprofen (Advil, Midol IB, Motrin, Nuprin, and others);naproxen sodium (Aleve, Anaprox); and ketoprofen (Actron, Orudis KT). A woman should start taking one of these medications before her pain becomes difficult to control. This might mean starting medication 1 to 2 days before her period is due to begin and continuing taking medication 1-2 days into her period. The best results are obtained by taking one of the NSAIDs on a scheduled basis and not waiting for the pain to begin. Prescription NSAIDs available for the treatment of dysmenorrhea include mefenamic acid (Ponstel) and meclofenamate (Meclomen). If a woman's dysmenorrhea are too severe to be managed by these strategies, her doctor might prescribe low doses of birth control pills containing estrogen and progestin in a regular or extended cycle. This type of approach can prevent ovulation and reduce the production of prostaglandins which, in turn, reduces the severity of cramping and causes a light menstrual flow. Use of an IUD that releases small amounts of the progestin levonorgestrel directly into the uterine cavity, has been associated with a 50 percent reduction in the prevalence of dysmenorrhea. In contrast, IUDs that do not contain hormones, such as those containing copper, may worsen dysmenorrhea.

Surgical treatment: In the past, many women with dysmenorrhea had an operation known as a D & C (dilation and curettage) to remove some of the lining of the uterus. This procedure is also sometimes used as a diagnostic measure to detect cancer or precancerous conditions of the uterine lining. Some women even resorted to the ultimate solution to menstrual problems by having a hysterectomy, surgery that removes the entire uterus. Today, when a woman has abnormally heavy and painful uterine bleeding, her doctor may recommend endometrial ablation, a procedure in which the lining of the uterus is burned away or vaporized using a heat-generating device. Treatment of secondary dysmenorrhea: The treatment of secondary dysmenorrhea depends on its cause. There are a number of underlying conditions which can contribute to the pain including:

 endometriosis (cells from the uterine lining tare located in other areas of the body) uterine fibroids (non-cancerous uterine growths that respond to estrogen levels) adenomyosis (a benign condition in which the cells of the inner uterine lining invade its muscular wall, the myometrium) pelvic inflammatory disease (PID) Adhesions (abnormal fibrous attachments between organs) Use of an intrauterine device (IUD) for contraception. All of these conditions should be first diagnosed by a physician who will then recommend the optimal treatment.

Menorrhagia
Menorrhagia exclusively when describing excessive quantity and hypermenorrhea for prolonged duration. Causes: In some cases, the cause of heavy menstrual bleeding is unknown, but a number of conditions may cause menorrhagia. Common causes include: Hormonal 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 hormonal imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding. Dysfunction of the ovaries. If ovulation does not occur in a menstrual cycle (anovulation), progesterone is not produced. This causes hormonal imbalance and may result in menorrhagia. 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. Polyps. Small, benign growths on the lining of the uterine wall (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. Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and painful menses. Adenomyosis is most likely to develop if you're a middle-aged woman who has had children. 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, you may need to remove it. 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.
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 Cancer. Rarely, uterine cancer, ovarian cancer and cervical cancer can cause excessive menstrual bleeding. 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. Medications. Certain drugs, including anti-inflammatory medications and anticoagulants, can contribute to heavy or prolonged menstrual bleeding. Improper use of hormone medications also can cause menorrhagia. 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. Risk factors Obesity Anovulation Estrogen administration (without progestogens) Prior treatment with progestational agents or oral contraceptives increases the risk of endometrial atrophy, but decreases the risk of endometrial hyperplasia or neoplasia Adolescent girls who have recently started menstruating. Girls are especially prone to anovulatory cycles in the first year and a half after their first menstrual period (menarche). Older women approaching menopause. Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles. Symptoms: The signs and symptoms of menorrhagia may include: Vaginal bleeding so heavy it soaks at least one pad or tampon an hour for more than a few hours Irregular vaginal bleeding Needing to wake up to change sanitary protection during the night Bleeding for a week or longer Passing large blood clots with menstrual flow Restricting daily activities due to heavy menstrual flow Symptoms of anemia, such as tiredness, fatigue or shortness of breath vaginal bleeding after menopause Diagnosis: o Ask about medical history and menstrual cycles. o Pelvic and physical examination o Blood tests. Check for anaemia, thyroid disorders or blood-clotting abnormalities. o Pap test. Collects cells from cervix for microscopic examination to detect infection, inflammation or changes that may be cancerous or may lead to cancer.

o Endometrial biopsy. Take a sample of tissue from the inside of uterus to be examined under a microscope. o Ultrasound scan. This imaging method uses sound waves to produce images of uterus, ovaries and pelvis. Based on the results of your initial tests, your doctor may recommend further testing, including: o Sonohysterogram: This ultrasound scan is done after fluid is injected, through a tube, into uterus by way of vagina and cervix. This allows to look for problems in the lining of uterus. o Hysteroscopy: A tiny tube with a light is inserted through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus. o Dilation and curettage (D&C): Diagnosis of menorrhagia can be certain of only after ruling out other menstrual disorders, medical conditions or medications as possible causes or aggravations of this condition. Complication: Excessive or prolonged menstrual bleeding can lead to other medical conditions, including: Iron deficiency anemia. Although diet plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual periods. Most cases of anemia are mild, but even mild anemia can cause weakness and fatigue. Moderate to severe anemia can also cause shortness of breath, rapid heart rate, lightheadedness and headaches. Severe pain. Heavy menstrual bleeding often is accompanied by painful menstrual cramps (dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to require prescription medication or a surgical procedure. Treatment: Drug therapy for menorrhagia may include: Iron supplements. If the condition is accompanied by anemia take iron supplements regularly. If your iron levels are low but not yet anemic, may be started on iron supplements rather than waiting until patient become anemic. Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea). Oral contraceptives. Aside from providing effective birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.

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 Oral progesterone. When taken for 10 or more days of each menstrual cycle, the hormone progesterone can help correct hormonal imbalance and reduce menorrhagia. The hormonal IUD (Mirena). This type of intrauterine device releases a type of progestin called levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and cramping. If you have menorrhagia from taking hormone medication, able to treat the condition by changing or stopping medication. Surgical management: Need surgical treatment for menorrhagia if drug therapy is unsuccessful. Treatment options include: Dilation and curettage (D&C). Operative hysteroscopy. This procedure uses a tiny tube with a light (hysteroscope) to view uterine cavity and can aid in the surgical removal of a polyp that may be causing excessive menstrual bleeding. Endometrial ablation. Using a variety of techniques, permanently destroys the entire lining of your uterus (endometrium). After endometrial ablation, most women have little or no menstrual flow. Endometrial ablation reduces ability to become pregnant. 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. Like endometrial ablation, this procedure reduces ability to become pregnant. Hysterectomy. Surgical removal of the uterus and cervix is a permanent procedure that causes sterility and cessation of menstrual periods. Hysterectomy is performed during anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.

Polymenorrhea
Definition: This means too frequent menstruation at regular interval of 2weeks but less than 3 weeks. Such cyclic bleeding can be normal in amount but when becomes heavy, the condition is called polymennorrhoea or epimenorrhoea. Any cycle shorter than 21days are considered abnormally short and will lead to more frequent menstruation and many more cycles in a year than normal. These periods are said to be frequent. The women whose menstrual cycle length is less than 21 days every time. The medical name is polymenorrhoea. Causes:

The factors can be responsible are the following: Endocrine disorders: this is due to anovulation, shortening of the proliferative phase. Constitutional disorders: Malnutrition, asthenia, psychological disturbances, stress, excessive exercise or medication. Pelvic disorders: chronic pelvic inflammatory disorder, chocolate cyst of the ovary. Treatment: Before institution of treatment identified the correct cause and institution of specific therapy according to cause. Some specific therapy include oral contraceptive pills, medication adjustment, life style changes such as exercise reduction, stress management, proper weight and others. The best advice to someone with irregular periods with no apparent medical illness is to relax, eat healthy, main good body weight and exercise moderately. Premenstrual Tension Many women experience premenstrual symptoms 7 to 10 days before the onset of bleeding. Etiological factors: Possibly due to excessive estrogen production The constantly increase in the extracellular fluid throughout the body Some cyclic disturbances of adrenal cortical function Symptoms: Irritability Lassitude Malaise Headache GI upset such as colon spasm, constipation Frequency of micturation Feeling of fullness Treatment: Its depend upon condition, elimination of excessive extracellular fluid by limited water intake and a salt free diet for the 10 days preceding menstruation. Saline purgatives and more powerful diuretics such as chlorthiazide in a single dose of 250mg or more from the onset of the symptoms until menstruation is established have been used with success. For the congestion of breast adequate support is essential and fluid restriction and elimination is probably the best treatment.
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Precocious menstruation If the menstruation start before the child reaches the age of 10yrs, the condition is reffered to as precocious menstruation. Dysfunctional Uterine Bleeding Definition: This is the excessive uterine bleeding where no organic cause (systematic, hematological or pelvic) can be detected. The nature of the bleeding is one of menorrhagia, polymenorrhoea, metrorrhagia and continuous bleeding preceded by amenorrhea. Incidence: In india dysfunctional uterine hemorrhage constitutes about 15-20% of all gynecological admission.

Causes: Table 1. Causes of dysfunctional uterine bleeding. Endocrine Infections Cushing's disease chlamydia immature hypothalamin-pituitary gonorrhea axis PID hyperprolacinemia Medications hypothyroidism hormonal agents menopause low-dose oral contraceptive pills obesity (OCPs) polycystic ovary disease nonprogestin-containing IUDs premature ovarian failure nonsteroidal anti-inflammatory drugs (NSAIDS) Stuctural lesions adenomyosis Norplant System coagulopathies progestin-only contraceptive (the "mini condyloma acuminata pill") dysplastic or malignant lesion of the tamoxifen cervix or vagina warfarin endometiosis Pregnancy endometrial cancer ectopic pregnancy uterine or cervical polyps incomplete abortion uterine leiomyomata pregnancy complications trauma

Description of Dysfunctional Uterine Bleeding Estrogen is a hormone that stimulates growth of the uterine lining. Usually, patients with DUB have menstrual cycles that are longer than usual, which allows the lining of the uterus to be exposed to estrogen for long periods of time. After ovulation has occurred, another hormone called progesterone is produced by the ovary. Progesterone causes changes that prepare the uterine lining for menstruation, so that the entire surface layer can fall off neatly, all within a few days. DUB occurs when there is an imbalance of hormones so that there is no regular monthly release of an egg. In this situation, without the action of progesterone, steady estrogen exposure allows the lining of the uterus to overgrow, with no orderly preparation for menstruation so that bleeding can begin from one area, followed a few days later by bleeding from another area. Steady estrogen exposure results in growth of the lining, but some areas may be thicker than others, or out of synchrony, so that bleeding can begin from one area, followed a few days later by bleeding from another area. Clinical manifestation: In some cases, bleeding is light, although unpredictable and possibly prolonged. Moderate to heavy bleeding persistent enough to cause anemia is not uncommon. In some cases, hemorrhage can be severe enough to require hospitalization and even blood transfusion. Investigation protocol:

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Treatment:

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Endometrial ablation is a method to destroy the lining of the uterus in order to stop or drastically decrease bleeding. This may be accomplished by putting a hot balloon placed in the endometrial cavity to burn the lining, or by a procedure to burn or cut out the endometrium with other instruments. About 50-75% of patients may stop having periods after endometrial ablation, at least initially, and 20-30% of patients note an acceptable decrease in the amount of bleeding. Unfortunately, 10% of patients see no improvement in their symptoms. Endometrial ablation should only be considered by women who dont want to have more children, and who have had a biopsy to make sure that endometrial hyperplasia and cancer are not the causes of the bleeding. Occasionally, women who have finished having children may also consider hysterectomy, especially if anemia is severe, symptoms are not helped by medication, or if patients cant tolerate the side effects of hormonal medications. Though endometrial ablation may result in shorter hospital stays and fewer complications in the short term, patients undergoing hysterectomy appear to have significantly better improvement in their symptoms and satisfaction in the long term. Up to 40% of women undergoing endometrial ablation may require another operation within 4 years because of recurrence of unacceptable symptoms.

Postmenopausal bleeding
Definition: Postmenopausal bleeding is defined as vaginal bleeding occurring over 12 months after periods have stopped in a woman of the age where the menopause can be expected. Hence it does not apply to a young woman who has had amenorrhoea from anorexia nervosa or a pregnancy followed by lactation. It can apply to younger women following premature ovarian failure or premature menopause. It is common and represents 5% of all gynaecology OPD attendances. Risk factors: It is likely to occur if exogenous oestrogens are taken. Polycystic ovary disease increases risk. Use of combined oral contraceptives decreases risk. Causes: Non-gynaecological causes including trauma or a bleeding disorder Use of hormone replacement therapy Vaginal atrophy Endometrial hyperplasia - simple, complex, and atypical Endometrial carcinoma usually presents as PMB but 25% occur in premenopausal women Endometrial polyps or cervical polyps Cancer of cervix (is cervical smear up to date?) Ovarian cancer, especially oestrogen-secreting (theca cell) ovarian tumours

Vaginal cancer is very uncommon. Cancer of vulva may bleed but the lesion should be obvious

Investigation: A transvaginal scan is used to measure endometrial thickness and 4mm is used as the cut-off point. Hysteroscopy may be performed as this gives a view of the inside of the uterus D&C is performed along with the hysteroscopy or a hysteroscopic guided biopsy is taken The accuracy of assessing endometrial thickness in women with diabetes and obesity has been questioned. Management: History and examination may possibly indicate cause but the dictum is that postmenopausal bleeding should be treated as malignant [cancer] until proved otherwise. Any causative factor is treated on the appropriate line and the women is kept under follow up. If no cause can be detected for one episode of bleeding following dilatation and curettage women is carefully followed up. In case of recurrence of bleeding , total hysterectomy with bilateral salpingo-oophaorectomy is advisable. Outcome:

Where pathology is found it needs to be treated and prognosis will depend upon the condition and, if malignant, the stage. After an initial hysteroscopy and biopsy have excluded uterine pathology there is no need to repeat the procedure unless there are very strong grounds for suspecting an occult cancer. If transvaginal ultrasound measured endometrial thickness of less than 5 mm it provides additional reassurance that there is no sinister underlying pathology. Most women who have negative investigations will have no further problems and failure to make a diagnosis is not uncommon.

Important points to keep in mind:

Most women with PMB will not have significant pathology but the dictum remains that postmenopausal bleeding is cancer until proved otherwise. PMB in women on HRT still needs investigation. An obvious lesion like atrophic vaginitis does not exclude another lesion. Many women are unable to distinguish between vaginal and urinary bleeding and some are unable to distinguish rectal bleeding. This may need investigating.

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