DISORDERS OF THE MENSTRUAL CYCLE 1- PRIMARY (SPASMODIC) DYSMENORRHOEA Intermittent suprapubic colicky pain starts with the onset of menstruation and peaks within 24 hours and then diminishes gradually within 72 hours. The condition usually affects young girls few years after menarche. Significant improvement may occur by age. A positive family history is frequently encountered and a strong psychological background is usually present . Colicky menstrual pains can be associated with other symptoms as nausea, vomiting and diarrhoea. Headache and fatigue are common complaints associated with vasomotor instability . • Aetiology a) Prostaglandins theory: Secretory endometrium produces excessive PGF2a which stimulates uterine contractions, sensitises pain nerve endings, and decrease uterine blood flow leading to ischaemia . b) Uterine ischaemia theory: Ischaemia of the myometrium during menstrual contractions results in accumulation of acid metabolites that can stimulate type C- pain neurons. Passage of menstrual blood with clots or casts results in increased uterine contractions . c) Mullerian anomalies: e.g. bicornuate uterus, cervical stenosis and imperforate hymen . d) Psychological: psychological factors influence the patient reactions to discomfort . Clinical picture Signs on abdominal or vaginal examination are irrelevant apart from mild abdominal and uterine tenderness at the time of pain . Treatment: General measures: explanation, reassurance, and support. Medical treatment for pain relief: anti prostaglandins e.g. mefenamic acid 500 mg 8-hourly. Hormonal treatment: OCS for suppression of ovulation. Surgical measures: as Cervical dilatation > 12 Hegar dilatation to destroy pericervical nerve endings, or presacral neurectomy are nowadays very rarely resorted only in intractable cases. SECONDARY (CONGESTIVE) DYSMENORRHOEA • Aetiology of secondary amenorrhea • Diagnosis – Natural history and physical examination. – Ultrasonogaphy, hysterosalpingography, hysteroscopy and laparoscopy can be used according to the underlying cause. • Treatment 1) General measures as analgesics, decongestants 2) Treatment of the underlying cause; endometriosis, fibroids, removal of IUD, chronic constipation. 3) Glycerine icthyol pessary to relief pelvic congestion. • Ovarian dysmenorrhoea ;It is a premenstrual dull aching pain occurring in one or both iliac fossae in patients due to ovarian congestion. The pain can be reproduced by pressure on the ovaries during bimanual examination . PREMENSTRUAL TENSION SYNDROME (PMS) Common symptoms (7-10) days Premenstrual 1. Psychic Disorders: Headache and mood changes including; depression, anxiety, tension, and irritability. 2. Bloating: water retention, breast tenderness, weight gain, and oedema of extremities. 3. Asthenia: Easy fatigability, lethargy, insomnia or hypersomnia, and lack of concentration. Incidence Approximately, 40% of women report uncomfortable symptoms related to their menstrual cycle, only 2 – 10 % might affect the life style. Nearly 5% of women will experience some degree of PMS in their lives, but many will not seek advice . A Psychiatric background is common resulting in an antisocial behaviour related to the period of recurrence of the menstrual cycle . Aetiology 1 .Dietary theory :hypoglycaemia, deficiency of vitamin B6 or B12 or essential fatty acids. 2 .Hormonal theory – Oestrogen role: Oestrogen has a central neurologic effect that can increase brain activity and may also contribute to drop in blood sugar level, apart from salt and water retention. – Progesterone: increases plasma MAO levels in luteal phase and cause depression by destroying serotonin and noradrenaline. 3 .Heredity appears to be a factor . Diagnosis 1. Clinical examination to rule out pelvic pathology. 2. Menstrual diary: the patient keeps a daily symptom diary for 2 months and if the symptoms occur 5 days before menses and disappear 5 days after menses PMS should be suspected. 3. Screening for psychiatric problems. Differential diagnosis 1. Psychiatric conditions or depression. 2. Early menopausal symptoms. Treatment 1. Diet control: • Eliminate caffeine, cigarettes and alcohol. • Dietary supplementation with primrose oil, vitamins (vit. B6 100mg daily), and calcium. 2. Supplemetary cyclic progesterone or gestagens. 3. Ovulation suppression by oral contracetive pills (OCPS), depot medroxy progesterone acetate I.M. injections (DMPA), or gonadotropin releasing hormone agonists (Gn RH agonists). Anovulation leads to disappearance of PMS. 4. Symptomatic treatment: • Diuretics for water retention in the premenstrual period (spironolactone 100 mg daily in luteal phase. • Analgesic for pain. • Bromocryptine for mastalgia (see galactorrhea and hyperprolactinaemia). 5. Selective serotinine reuptake inhibitors is the drug of choice for severe PMS e.g. Fluoxetinc 20 mg. 6. Antidepressant drugs in severe cases. ABNORMAL UTERINE BLEEDING DEFINITIONS AND CLINICAL TYPES OF ABNORMAL UTERINE BLEEDING 1. Menorrhagia; Excessive heavy menstruation. It is cyclic bleeding which is excessive in amount or duration or both (>80 ml/cycle). 2. Polymenorrhea; Frequent menstruation. It is cyclic bleeding which is normal in amount, but occurs at short intervals of less than 21 days. 3. Metrorrhagia; Bleeding in between menstrual cycles. It is acyclic or irregular bleeding of any amount not related to menstruation. DYSFUNCTIONAL UTERINE BLEEDING (DUB) I. OVULAR DUB A) Dysfunctional polymenorrhea: B) Dysfunctional menorrhagia: – Premature endometrial shedding – Delayed endometrial shedding Diagnosis is by endometrial biopsy and serum progesterone levels. Treatment is by oral progestogen from the 15th day of the cycle for 10 days (i.e. days 15-25) to support the endometrium and restore the cycle length and pattern. II. ANOVULAR DUB A) Metropathia haemorrhagica Aetiology Pathology a.The uterus: – The myometrium shows mild myo-hypertrophy, with slightly enlarged size of the uterus. – The endometrium is thick, hyperplastic and may be polypoidal. Microscopically showing a picture known as simple cystic hyperplasia (formerly cystic glandular hyperplasia) ; where the glands and stroma are hyperplastic, glands show cystic dilatation with disparity in size, giving a swiss cheese appearance. There is no evidence of secretory activity in the endometrium. b. The ovaries (one or both ovaries): Show either a single follicular cyst (maximum 5.0 cm) or multiple smaller cysts (1-2 cm each) lined by granulosa cells without evidence of luteinization (No. corpus luteum). Diagnosis of Metropathia haemorrhagica (MH) 1. History: Prolonged excessive bleeding preceded by short periods of amenorrhea, usually in the premenopausal period. Bleeding is irregular, painless and usually profuse. 2. Clinical examination & Ultrasonography: see diagnosis of DUB. 3. Endometrial biopsy: reveals simple cystic hyperplasia. Differential Diagnosis of MH DIAGNOSIS OF DUB : a) History b) Examination c) Ultrasonography d) Endometrial biopsy: TREATMENT OF DUB A) Medical treatment of DUB 1. Non hormonal therapy 2. Hormonal therapy B) Surgical treatment of DUB 1. Endometrial ablation: 2. Hysterectomy: Threshold Bleeding The ovary produces small amounts of oestrogen that fluctuate above and below the threshold level required to support the endometrium, and avoid its irregular breaking down. Treatment: is by cyclic oral combined hormonal therapy where – Oral oestrogen is given for the 1st 10 days of the onset of menstruation (days 1-10) – Followed by combined estrogen and progesterone for the next 14 days (days 11-25). – The regimen is usually repeated for 3 cycles.