Common Reproductive Concerns & Menopause

1. Common Reproductive Concerns & Menopause Presented by: Rahhegeh Awni 27/01/2011

2. Pathophysiology of menstrual loss • Immediately prior to menstruation intense spiral arteriole vasoconstriction occurs. • - The spiral arterioles dilate and menstrual bleeding occurs. - Platelet adhesion in endometrial vessels is initially suppressed but with increased blood extravasation, damaged vessel ends are sealed by intravascular plugs of platelets and fibrin

3. - By 20 hours after the onset of menses, when most of the endometrial sheddinghas occurred, haemostasis occurs by intense spiral arteriole vasoconstriction. - Endometrial regeneration begins within 36 hours of the onset of menses, while some shedding is still occurring.

4. The normal menstrual cycle. Length 28 ± 7 days Duration of menstrual flow 4 ± 2 days Menstrual blood loss: 40 ± 20ml1 95% of normal women lose less than 60 ml of blood with each menses. Loss >80 ml is correlated with a lower mean haemoglobin, haematocrit and serum iron level.

5. Definitions applied to abnormal uterine bleeding 1- Dysfunctional uterine bleeding – abnormal uterine bleeding with no demonstrable organic cause from the reproductive tract 2- Menorrhagia – bleeding greater than 80ml occurring at regular intervals 3- Metrorrhagia – irregular uterine bleeding at frequent intervals that is variable 4- Menometrorrhagia – uterine bleeding that is prolonged and occurs at completely irregular intervals 5- Polymenorrhoea – uterine bleeding occurring at regular intervals less than 21 days

6. 6- Intermenstrual bleeding – bleeding between periods of variable amounts 7- Postmenopausal bleeding – bleeding occurring at more than 1 year after the last menses in a woman with ovarian failure 8- Postcoital bleeding – bleeding occurring after intercourse 9- Premenstrual spotting – scanty bleeding that occurs a few days to a week before menses

7. Menstrual Disorders • Women typically have menstrual cycles or approximately 40 years. • Once the predictable patterns is established, women may worry about any deviation from that patterns. • Menstrual disorders can be a source of severe distress & concerns for a woman as she wonder what is wrong.

8. The common menstrual problems • Amenorrhea • Menorrhagia • Dysmenorrhea • metrorhgia • Cyclic perimenstrual pain & discomfort. • Alterations in cyclic bleeding.

9. Amenorrrhea • Amenorrhea: is the absence or cessation of menstrual flow, is a clinical sign of a variety of disorders. • When amenorrhea is a clinical problem? • The absence of both menarche & secondary sexual characteristics by age 14. • The absence of menses by age of 16 regardless of presence of normal growth and development ( primary amenorrhea) • A 6-month cessation after a period of menstruation ( secondary amenorrhea).

10. Cont.. • Exercise –associated amenorrhea can occur in women undergoing vigorous physical & athletic training. • Stress-associated amenorrhea in the adolescent is likely similar to the disorder found in young reproductive-aged adults and is termed hypothalamic amenorrhea. The keydefect is an abnormality in the secretion of GnRH (James H & Arthur H. 2008) • Amenorrhea is one of the clinical signs of anorexia nervosa • Calcium loss of bone as seen in postmenapausal women may occur

11. Primary amenorrhea - Primary amenorrhea: the absence of menstruation by age 16. Prevalence: 1-2 % of girls in USA

12. Secondary amenorrhea • Is the absence of menstruation for more than 6 months or for more than three cycles for a woman who had previously regular menstruation. Prevalence: 2-5 % of women

13. causes - Dysfunctional hypothalamus 35% caused by drugs, stress, diet and exercise. 2- Polycystic ovarian dysfunctio 30%. 3- Pituitary disease 20% like microadenomas 4- Premature ovarian failure

14. Causes of Amenorrhea in general • Pregnancy. • Interruption in the hypothalamic-pituitary-ovarian-uterine axis. • Anatomic abnormalities. • Endocrine disorders (hypothyroidism or hyperthyroidism) • Chronic diseases (type 1 DM) • Medications ( phenytoin) • Eating disorders. • Strenuous exercise. • Emotional distress • Oral contraceptive use. • menapause

15. Research Findings • A qualitative study investigated Brazilian women's views regarding the suppression of menstruation using hormones. • Sixty-four women, 21–51 years old participated in the study. • Women see that menstruation associate with femaleness, youth, fertility and health. • Most women, although they would like to be free from menstruation, feared negative consequences of induced amenorrhea (Amaral M et al. 2005)

16. Hypogonadtropic amenorrhea • Reflecta a problem in hypothalamic pitiutary axis. • CAUSES • - Lesions or genetic inability to produce FSH&LH. • - Hypothalamic suppression as a result of stress, body fat to lean ratio is inappropriate.

17. Assessment - Assessment begins with thorough history and physical examination. - Confirm that woman is not pregnant - Assessment process depends on a woman’s age, and whether or not she has previously menstruated.

18. TREATMENT • - Treatment for amenorrhea depends on the underlying cause.  • - Sometimes lifestyle changes can help if weight, stress, or physical activity is causing the amenorrhea.  • - Other times medications and oral contraceptives can help the problem.  • -contact of health care provider.

19. Management Counseling & educating of pts are primary interventions • Decrease or discontinue medications known to affect menstruation. • Many causes are reversible as weight loss and strss • Correct weight loss • Deal effectively with psychological stress • Deep breath exercise & relaxation techniques • Decrease the intensity or duration of vigorous exercise

20. Cont. • - Adolescents may take promocripitine (paroldil) which can reduce high prolactin level by acting on the hypothalamus and initiating menstruation each month. • - If menstrauation is delayed and pregnancy is suspected it should be stopped

21. Menorrhagia

22. Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. - Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhea).

23. - Menorrhagia affects approximately 20 per cent of otherwise healthy women (i.e. it adversely affects lifestyle) and approximately 5 percent of women of reproductive age will consult their general practitioner with menstrual dysfunction. - Up to 20 per cent of women have a hysterectomy by the age of 60 and in 50 per cent a normal uterus is removed.

24. signs and symptoms - Menstrual flow that soaks one or more sanitary pads or tampons every hour for several consecutive hours - The need to use double sanitary protection to control your menstrual flow - The need to change sanitary protection during the night - Menstrual periods lasting longer than seven days - Menstrual flow that includes large blood clots Heavy menstrual flow that interferes with regular lifestyle- Tiredness, fatigue or shortness of breath (symptoms of anemia))

25. causes - Anatomic lesion - Inflammatory process - Blood dyscarsias - Systemic disease - Carcinoma - Hormonal change

26. CONT. - Fibroids - Endomeriosis - Endometrial cancer - Anticoagulant - DUB - Hyperthyroidism - haemophilia

27. Medical conditions to be excluded asa cause of menorrhagia 1- Hypothyroidism - Hypothyroidism may be associated with abnormal uterine bleeding. - With normalisation of the thyroid-stimulating hormone (TSH) women become euthyroid and abnormal uterine bleeding resolves.

28. 2- Liver disease Cirrhosis of the liver interferes with the ability to metabolise and conjugate oestrogens. Thus the levels of free oestrogen are increased, causing hyperstimulation of the endometrium and uterine bleeding.

29. 3- Iatrogenic causes These include steroids used for contraception, hormone replacement therapy, corticosteroids, anticoagulants, tranquillizers, antidepressants, digitalis, dilantin and intrauterine devices.

30. Medical management of menorrhagea 1- Antifibrinolytic agents Tranexamic acid – an antifibrinolytic Dosage: 1–1.5 g orally three to four times daily for the period of bleeding. This is the first line of therapy. The action of tranexamic acid is via a strong inhibitory effect on the activation of plasminogen, i.e. the conversion of plasminogen to plasmin in the fibrinolytic system. It is excreted unchanged in the urine. Maximal levels are achieved within 2–3 hours. It results in a 50 per cent reduction in menstrual blood loss (MBL). Success is greatest in women with the greatest loss of menstrual blood.

31. 2-Aminocaproic acid Dosage: 3g four times a day. It reduces menstrual blood loss by up to 60 per cent of women compared with pretreatment values. - The reduction in menstrual loss does not persist after stopping RX.

32. 3- The combined oral contraceptive pill Reduces average MBL by 40–50 per cent 70–80 per cent of patients benefit Few side effects Avoid in women aged >35 who are cigarette smokers Avoid in those with a body mass index (BMI) of >30

33. 4 - Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in reducing menstrual blood loss in women with menorrhagia.

34. SURGICAL TREATMENT - Up to 50 per cent of hysterectomies are done for dysfunctional uterine bleeding. Mortality for hysterectomy is 6–11 per 10 000 procedures and morbidity is 3–40 per cent. - Operative complications from ablation may occur in up to 6 per cent for first time procedures,and 15 per cent for repeat ablation. - Patient satisfaction with endometrial ablative techniques, including transcervical resection of the endometrium, is high - Post menopausal HRT after endometrial ablation requires a progestogen.

36. Cyclic perimenstrual pain & discomfort • Cyclic perimenstrual pain & discomfort (CPPD): a new concept develop by nurse science team, it is a health problem can have a significant impact on the quality of life or a woman. • CPPD includes: • Dysmenorrhea • Premenstrual syndrome (PMS) • Premenstrual dysphoric disorders (PMDD)

37. Dysmenorrhea • Dysmenorrhea, or painful menstruation, occurs at or a day before the onset of menstruation and disappears by the end of menses. • Dysmenorrhea is classified as primary or secondary.

38. Dysmenorrhea • Dysmenorrhea is the most common gynecologic problems in women • Many adolescents have dysmenorrhea in the first 3 years after menarche.

39. Cont .. • Young adult women ages 17-24 years are most likely to report painful menses. • Symptoms usually begin with menstruation. • The range and severity of symptoms are different from woman to woman, and from cycle to cycle in the same woman. • Symptoms may last several hours to several days.

40. Cont.. • Pain is usually located in the suprapubic area or lower abdomen. • Pain is described as sharp, cramping, or gripping, and it may radiate to the lower back or upper thigh.

41. Risk factors • Smoking • Obesity • Early menarche • Nulliparity • Stress

42. Cont.. • Dysmenorrhea is differentiated as: • Primary dysmenorrhea 2. Secondary dysmenorrhea

43. Primary dysmenorrhea • Primary dysmenorrhea is defined as cramps without underlying disease. • - Prostaglandins F2 and F2, which are produced by the uterus in higher concentrations during menses, are the primary cause.

44. Primary dysmenorrhea • It is a condition associated with ovulatory cycles. • It has a biochemical basis& arise from the release of prostaglandins with menses. • It usually appears 6-12 months after menarche when ovulation is established. • The symptoms are definitely related to ovulation & don’t occur when ovulation is suppressed. • Dysmenorrhea typically disappears after a first pregnancy and does not occur if cycles are anovulatory.

45. Signs & Symptoms • Lower abdominal cramps • Backache • Weakness • Sweats • Gastrointestinal symptoms( anorexia,nausea, vomiting, & diarrhea). • CNS symptoms ( dizziness, headache, & poor concentration) NOTE( Pain begins at the onset of menstruation and lasts 8-48 hours).

46. Management • Important components of midwife care are information and support. • Offering of different alternatives to alleviate dysmenorrhea: • Heat (heating pad or hot bath) • Massaging the lower back. • Soft, rhythmic rubbing of the abdomen. • Progressive relaxation, yoga, & acupuncture

47. Cont.. • Exercise • Maintaining good nutrition at all times • Decrease salt & refined sugar intake 7-10 days before expected menses may reduce fluid retention. • Decreasing red meat intake • Medications (NSAIDs, combined OCPs) • Herbal preparations (Ginger, black cohosh)

48. Secondary dysmenorrhea • It is acquired menstrual pain that develops later in life than primary dysmenorrhea, typically after age 25. • It is associated with pelvic pathology such as adenmyosis, endometriosis, pelvic inflammatory disease, endometrial polyps, uterine fibroid, or use of IUD.

49. Signs & Symptoms • Dull pain starts few days before menses, but it can be continue through the first days of menses. • Lower abdominal aching radiating to the back or thighs • Feelings of bloating or pelvic fullness.

50. Management • Treatment directed toward removal of the underlying pathology • Many measures described for primary dysmenorrhea can be helpful for women with secondary dysmenorrhea.