Menstrual Disorders

Menstrual disorders are amongst the commonest of gynecological complaints. Normal menstruation occurs at the age of 11-13 yrs. The menstrual cycle is 25–35 days in duration and bleeding lasting an average of 5 days. Total blood flow in a normal cycle is between 25 and 80 ml. Any deviation from the normal cycle is a disorder.

Menstrual disorders type

These are classified here on clinical grounds—

1. Precocious menstruation — menstruation starts before age of 10 yrs
2. Amenorrhoea — the absence of menstruation
3. Oligomenorrhoea — scanty menstruation
4. Dysmenorrhoea — painful menstruation
5. Menorrhagia — Heavy menstruation

Precocious menstruation

Menstrual disorders where menstruation is before 8 years of age is called precocious menstruation. Sexual development begins too early in young girls, resulting in early menstruation and other signs of sexual maturation.

Causes

1. Anxiety
2. Childhood obesity
3. Endocrine disorders
4. Exposures to pesticides (with estrogenic activity)
5. Fatigue
6. Genetics
7. History of abuse
8. Overwork
9. Stress
10. Urbanization and sexualization of society

Symptoms and signs

1. Specific body odor
2. Acne                                     
3. Back pain
4. Breast development
5. Breast tenderness
6. Cramping of the abdomen and thigh (during menstruation)
7. Irritability
8. Pubic or underarm hair development
9. Rapid height growth
10. Aggressive or withdrawal behaviour  

Investigations

FSH level in blood

Treatment

1. Lifestyle changes like rest, joy time, exercise program)
2. Subcutaneous injection of long-acting analogue of GnRH (gonadotropin-releasing hormone) for up to 3 yrs suppress menstruation
3. Surgery (for pituitary, ovarian tumors)

Complications

1. Breast cancer
2. Depression
3. Early-onset of sexual activity
4. Eating disorders
5. Illicit drug use and Smoking
6. Increased menstrual distress
7. Negative body image

Amenorrhoea

Amenorrhoea ; menstrual disorders where there is no bleeding. It is of two types.

1. Physiological. During pregnancy and lactation, there is the suppression of menstruation due to hormonal changes leading to physiological amenorrhoea. Then in pre-puberty age, there is no menstruation. Similarly in post-menopausal age, there is amenorrhoea due to reduced hormones.
2. Pathological. It is two types-Primary and Secondary.

Primary amenorrhoea

• Menstruation does not begin by age of 14
• Menstruation does not begin by age of 16 in spite of well developed secondary sex characters

Secondary amenorrhoea

Amenorrhoea of at least 6 months in a previously normally menstruating woman. 

Causes

Primary Amenorrhoea

1. Congenital obstructive defects in the lower genital tract — Non-canalization of cervix, vagina, or Imperforate hymen
2. Rohitansky-Hauser-Kuster syndrome(congenital absence or gross hypoplasia of uterus)
3. Congenital aplasia of ovaries(turner’s syndrome)
4. Intersexual (pseudohermaphroditism)
5. Hypopituitary dwarfism (empty sella)
6. Hypothyroid cretinism 
7. Delayed puberty
8. Hypothalamic deficiency of GnRH
9. Organic brain lesions (tumors, infections)
10. Kallman syndrome

Secondary Amenorrhoea

• Acquired obstruction in the lower genital tract

1. Amputation of cervix
2. Cone biopsy
3. Trachelorrhaphy
4. Cauterization
5. Radiotherapy

• Uterine factors

1. Hysterectomy
2. Destruction of the endometrium (genital tuberculosis, Asherman’s syndrome, intracavity radiotherapy)

• Ovarian factors

1. Destruction of ovaries(disease, radiation, oophorectomy)
2. Ovarian failure (Hypohormonal amenorrhoea)
3. Hyperhormonal amenorrhoea
4. PCOD
5. Premature menopause       
6. Masculinizing tumours (Arrhenoblastoma, hilus cell tumour, masculinizing luteoma, adrenal-like tumours)

• Pituitary factors

1. Psychogenic (anorexia nervosa, pituitary shock, stress, vigorous exercise, pseudocyesis)
2. Basophil adenoma (Cushing disease)
3. Acidophil tumors (Gigantism, Acromegaly)
4. Pituitary failure (Chromophobe adenoma, cysts, Simmonds disease, Sheehan’s syndrome)
5. Chiari-Frommel syndrome
6. Hyperprolactinaemia
7. Prolactinoma

• Adreno-genital syndrome, adrenal –cortical tumors, adrenal failure
• Hyperthyroidism    
• Hypothyroidism-late stage 
• Diabetes mellitus    
• Severe anaemia   
• Fulminating tuberculosis   
• Extreme obesity      
• Chromosomal abnormalities 

1. Kleinfelter’s  syndrome (XXY)
2. Super female (trisomy X or XXX)

Symptoms and Signs

1. Abdominal, pelvic, or lower back pain that can be severe
2. Bleeding or spotting between periods
3. Breast discharge
4. Eating disorders(unexplained weight gain or loss)
5. Excess/total absence of  hair growth on the body
6. Fatigue
7. Headaches
8. Irritability and mood changes
9. Malaise or lethargy

Investigations

1. Blood test
   • Hb
   • ESR
   • Cholesterol
   • Sodium and potassium
   • RBS/FBS
   • Full blood count
   • Hormones (FSH, LH, prolactin, oestradiol)
2. Urine test
   • 17-ketosteroids
   • 17-hydroxycorticoids
3. X-rays
   • Chest
   • Pituitary fossa
4. Hysterosalpingography
5. Vaginal smears
6. Diagnostic curettage
7. Karyotyping
8. USG
9. Laparoscopy
10. Hysteroscopy
11. Therapeutic test with hormones (estrogen, progestogen)

Treatment

General measures

• Assurance
• Balanced diet
• Calm mind
• Moderate exercise
• Rest

Specific

• Treating the causative disease cures the amenorrhoea (medically/surgically)
• Ovulation inducing medicines stimulate ovaries; hence menstruation

Oligomenorrhoea

Menstrual disorders where menstruation is less. Menstrual periods occur at intervals of greater than 35 days, with only four to nine periods in a year.

Causes

• PCOS
• Puberty
• Female Athlete Triad (eating disorders, amenorrhoea/oligomenorrhoea and decreased bone mineral density)
• Adrenal hyperplasia
• Eating disorders                                      
• Diabetes mellitus                                
• Hypothyroidism                                       
• Thyrotoxicosis                                             
• Hyperprolactinemia
• Stress (emotional or physical)
• Drugs
• Perimenopause

Symptoms and Signs

1.  Menstrual periods at intervals of more than 35-36 days
2. Unusually light menstrual flow
3. Irregular menstrual periods with the unpredictable flow – only 4 to 9 periods in the whole year
4. Infertility

Treatment

The treatment should be done according to the main cause of oligomenorrhea.

Complications

1. Cardiovascular diseases
2.  Infertility
3. Osteoporosis
4. Uterine cancer

Dysmenorrhoea

It means painful menstruation. This is of two types.

Primary dysmenorrhoea – Pain isn’t caused by a specific condition

Secondary dysmenorrhea – Pain caused by a specific condition, such as endometriosis or fibroids.

Causes

Primary dysmenorrhoea — An increase in the amount of prostaglandins (chemicals that contract the muscles of the uterus) in the body.

Secondary dysmenorrhoea —

1. Endometriosis  
2. Fibroids or endometrial polyps  
3. Pelvic inflammatory disease     
4. Adenomyosis
5. Early menarche    
6. Smoking

Symptoms and Signs

1. Clots are passed in the menstrual blood
2. Diarrhoea /constipation
3. Fainting
4. Gripping pain, constant ache
5. Headache
6. Low abdomen pain radiating to the lower back and legs
7. Nausea and vomiting
8. Tender breasts and a swollen abdomen (continue throughout the period)
9. The first 24 hours is the most painful
10. Typically, the pain starts on or before the period starts

Treatment

• General

A hot bath, heating pad on the abdomen, regular exercise ( walking, swimming, running, bicycling, and aerobic dance)

• Medicines
• Surgery, as and when required

Menorrhagia

Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. It is possible to estimate the amount of bleeding by the number of tampons or pads a woman uses during her period.

Causes

• Hormonal imbalance
• Dysfunction of the ovaries
• Uterine fibroids
• Polyps
• Adenomyosis
• Intrauterine device (IUD)
• Pregnancy complications (ectopic pregnancy)
• Cancer (uterine, ovarian, cervical)            
• Inherited bleeding disorders (Von Willebrand’s disease)
• Other medical conditions–

1. Pelvic inflammatory disease (PID)
2. Thyroid problems
3. Endometriosis
4. Liver or kidney disease

• Psychological upsets and overwork
• Obesity
• Anovulation
• Medications ( anti-inflammatory medications, anticoagulants, hormone medications)

Investigations

• Blood tests — Thyroid hormone, Blood-clotting factor
• Pap smear
• Endometrial biopsy
• Ultrasound scan
• Sonohysterogram
• Hysteroscopy
• Dilation and curettage (D and C)

Treatment

A. Self-care- Menstrual disorders need great care.

1. Add fiber to diet by eating more fruit, vegetables, and whole grains
2. Avoid anxiety and tension
3. Avoid soya products, alcohol, saturated fats, and junk food
4. Avoid taking aspirin
5. Avoid vigorous exercise
6. Bed rest
7. Cold showers
8. Eat foods with vitamin K such as leafy vegetables, cheese, liver, and asparagus
9. Increase the amount of iron and vitamin C in the diet

B. Medicines

C. Surgery

1. Dilation and curettage (D and C)
2. Operative hysteroscopy
3. Endometrial ablation
4. Endometrial resection
5. Hysterectomy