1 MENSTRUAL IRREGULARITIES

2 dysmenorrhoea

3

4 DYSMENORRHOEA DEFENITIONPainful menstruation Cases of painful menstruation of sufficient magnitude so as to incapacitate day to day activities

5 TYPES PRIMARY There is no identifiable pelvic pathology SECONDARYPain occur due to a pelvic pathology

6 primary DYSMENORRHOEA

7 INCIDENCE OF PRIMARY DYSMENORRHOEA5- 10%

8 CAUSES OF PRIMARY DYSMENORRHOEADYSRYTHYMIC UTERINE CONTRACTION UTERINE HYPOXIA AND ISCHEMIA PAIN

9 CAUSES OF PRIMARY DYSMENORRHOEAAdolescents Related to ovulatory cycle Psychosomatic factors Tension and anxiety Lower pain threshold Abnormal anatomic and functional aspects of uterus Stenosis at the internal os In appropriate law of polarity Uterine myometrial hyperactivity Imbalance in the autonomic and nervous control Role of vasopressin Role of prostaglandin

10 CLINICAL FEATURE OF PRIMARY DYSMENORRHOEABegins few hours before or just with the onset of menstruation Last for few hours may extend to 24 hrs but rarely 48hrs Spasmodic and confined to lower abdomen and may radiate to back and medial aspect of thigh Nausea Vomiting Fatigue Diarrhoea Head ache Vasomotor changes – pallor,cold,sweat and fainting

11 TREATMENT OF PRIMARY DYSMENORRHOEAImprove general health Psychotherapy Explanation and assurance Mild analgesic and anti spasmodic SEVERE CASES Prostaglandin synthetase inhibitors Mefanamic acid mg Flufenamic acid mg hrly Propionic acid derivative Ibuprofen 400mg hrly Oral contraceptive pills

12 SURGICAL Rx OF PRIMARY DYSMENORRHOEADilatation of cervical canal Bilateral block of the pelvic plexus (Para cervical block with alcohol) Pre sacral neurectomy

13 SECONDARY DYSMENORRHOEA

14 DEFENITION Pain occur in the presence of a pelvic pathology

15 CAUSES OF SECONDARYDYSMENORRHOEAPremenstrual pelvic congestion or increased vascularity Increased tension in the pelvic tissue Pain

16 CAUSES OF SECONDARYDYSMENORRHOEAChronic pelvic infection Pelvic endometriosis Adenomyosis Uterine fibroid Endometrial polyp IUCD in utero

17 CLINICAL FEATURES Pain is dullSituated in the back and front without any radiation Appears 3-5 days prior to the period Relieves with the start of bleeding

18 TREATMENT MEMBRANEOUS DYSMENORRHOEA Shedding of big endometrial castsDeficiency of tryptic ferment Rx ---same as primary dysmenorrhoea OVARIAN DYSMENORRHOEA Appears 2-3 days before menstruation Dull Distributed to one or both quadrant MITTELSCHMERZ’S SYNDROME Appears in the mid menstrual period Situated in the hypogastrium or to either iliac fossa Nausea and vomiting is absent Last more than 12hrs Vaginal bleeding or excessive vaginal discharge Rx --- Assurance and analgesics

19 Premenstrual syndrome

20 DEFINITION Premenstrual syndrome is a psycho neuro endocrine disorder of unknown etiology often noticed just prior to menstruation

21 CAUSES LINKED TO THE LEUTEAL PHASEAlteration in the level of estrogen and progesterone Decreased synthesis of serotonin Withdrawal of endorphins Psychological and psychosocial factors

22 CLINICAL FEATURES Abdominal bloating Breast tendernessSwelling of the extremities Weight gain Irritability Depression Insomnia Dyspareunia Anxiety Head ache Loss of concentration

23 TREATMENT GENERAL Assurance Avoidance of salt, caffeine and alcoholPyridoxine 100mg,BD Diuretic – Frusemide 20mg Alprazolam 0.25mg (anxiety and depression) Fluoxetine HORMONES Oral contraceptive pills(Suppress ovulation) Progestogen 10mg (from 5th day of cycle for 20days) Bromocriptine 2.5mg(relieves breast discomfort) SUPPRESSION OF OVARIAN CYCLE Danazol mg (produce amenorrhoea) GnRH analouges (Gonadal steroids are suppressed)

24 Menorrhagia / HYPERMENORRHOEA

25 DEFINITION Menorrhagia is defined as cyclic bleeding at normal intervals Bleeding is either excessive in amount or duration or both

26 CAUSES ORGANIC Fibroid uterus Adenomyosis Pelvic endometriosisIUCD in utero Chronic tubo-ovarian mass Tubercular endometritis Retroverted uterus SYSTEMIC Liver dysfunction CCF Severe hypertension ENDOCRINAL Hypothyroidism Hyperthyroidism HEMATOLOGICAL DISORDERS ITP Leukemia Von willebrand’s disease FUNCTIONAL Hypothalamo – pituitary ,ovarian – endometrial axis

27 DIAGNOSIS Long duration of flow Passage of big clots Pallor Low Hb

28 TREATMENT Appropriate to the cause for menorrhagia

29 EPIMENORRHOEA/ POLYMENORRHOEA

30 DEFINITION It is defined as cyclic bleeding where the cycle is reduced to an arbitary limit of 21 days or less and remains constant at that frequency If the frequent cycle is associated with excessive and prolonged bleeding, it is called epimenorrhagia

31 CAUSES Hyper stimulation of the ovary by the pituitary hormoneAdolescence Preceding menopause Following delivery and abortion PID(Ovarian hyperemia) Ovarian endometriosis (Ovarian hyperemia)

32 TREATMENT Hormonal Therapy

33 metrorrhagia

34 DEFINITION Metrorrhagia is defined as irregular acyclic bleeding from the uterus Bleeding from any part of the genital tract is included under metrorrhagia Contact bleeding or inter menstrual bleeding is also included

35 CAUSES CA cervix Polyp Infection Cervical endometriosisOvular bleeding IUCD Decubitus ulcer

36 TREATMENT Malignancy should be excludedTreatment to the underlying pathology

37 MENOMETRORRHAGIA

38 DEFINITION When the bleeding is so irregular and excessive that the menses cannot be identified at all

39 CAUSES OF ACYCLIC BLEEDINGCAUSES OF CONTACT BLEEDING CA Cervix Mucous polyp of cervix Ectopy of cervix Infection Cervical endometriosis CAUSES OF INTERMENSTRUAL BLEEDING Urethral caruncle Ovular bleeding IUCD in utero Decubitus ulcer

40 TREATMENT Malignancy should be excludedTreatment to the underlying pathology

41 oligomenorrhoea

42 DEFINITION Menstrual bleeding occuring more than 35 days apart and which remains constant at that frequency is called oligomenorrhoea

43 CAUSES Age Obesity Stress and exercise PCOD HyperprolactenaemiaHyperthyroidism Androgen producing tumour Tubercular endometritis

44 hypomenorrhoea

45 DEFINITION When the menstrual period is unduly scanty and last for less than 2 days,it is called hypomenorrhoea CAUSES Uterine synachia Endometrial tuberculosis OCP Thyroid dysfunction Premenopausal period Malnutrition

46 amenorrhoea

47 DEFINITION Absence of menstruation

48 TYPES PRIMARY Delay of menarche past 17 years of age SECONDARYMenses ceases sometimes after menarche

49 CAUSES FOR PRIMARY AMENORRHOEAAnatomical defects in the structure of uterus and vagina Imperforate hymen Little or no development of secondary sex characteristics Genetic defects Intracranial lesions Pituitary failure

50 CAUSES FOR SECONDARY AMENORRHOEAOrganic brain disease Ovarian neoplasm Polycystic ovary Nutritional Psychological disturbances Oral contraceptives

51 TREATMENT Treatment of underlying pathology

52 NURSING MANAGEMENT Medical evaluation Physical examinationVaginal smear Estrogen level TFT CBC Urinalysis Blood glucose level