Menstrual Disorders

There are several common disorders associated with the menstrual cycle that midwives and nurses frequently encounter in clinical practice. These include:

• Amenorrhoea (Absence of periods)
• Dysmenorrhoea (Painful periods)
• Menorrhagia (Heavy or prolonged bleeding)
• Metrorrhagia (Irregular bleeding between periods)
• Polymenorrhoea / Epimenorrhoea (Frequent periods)
• Dysfunctional Uterine Bleeding (DUB) (Abnormal bleeding with no organic cause)
• Endometriosis (Misplaced uterine tissue)

1. Amenorrhoea

Amenorrhoea refers to the complete absence of menstruation in a female during her reproductive age.

Types of Amenorrhoea

• Primary Amenorrhoea: This is the complete failure of menses to start by the age of 16 years. A common example is an imperforate hymen, where the girl actually menstruates internally, but the thick membrane blocks the blood from coming out.
• Secondary Amenorrhoea: This is the cessation (stopping) of menses in a woman who has previously had normal menstrual cycles. It is officially diagnosed as secondary amenorrhoea when she goes for a period of 6 months or more without seeing her menses.

Causes of Amenorrhoea

The causes can be natural (physiological), anatomical, or hormonal:

• Physiological Causes: Pregnancy and lactation. During pregnancy, the high levels of Oestrogen and Progesterone ensure the endometrium remains intact, resulting in no menses. During lactation, the hormone Prolactin is secreted in massive quantities by the anterior pituitary gland. This partially suppresses the Luteinizing Hormone (LH), meaning ovarian follicles might grow, but ovulation never occurs.
• Hypothalamic Dysfunction: These patients have abnormally low levels of Follicle Stimulating Hormone (FSH) and LH. This includes congenital syndromes associated with abnormal hypothalamic-gonadal function. A specific example is Kallmann’s Syndrome (absence of the hypothalamus or congenital hypogonadotrophic hypogonadism), characterized by a lack of secondary sexual characteristics.
• Pituitary Disorders: Conditions leading to elevated levels of prolactin (Hyperprolactinaemia), or tumors of the pituitary gland.
• Congenital Abnormalities: Anatomical defects such as an imperforate hymen, vaginal septum, absence of the uterus, presence of a uterus but no endometrial lining, absence of ovaries, or extreme narrowing of the cervix (cervical stenosis).
• Psychological & Environmental: Extreme fear, severe anxiety, high excitement, or a sudden change of environment or occupation.
• Pseudoamenorrhoea: Meaning "false" amenorrhoea. A woman psychologically convinces herself she is pregnant when she is not, causing her periods to stop.
• Medical & Surgical Causes: After a hysterectomy or surgical removal of both ovaries (bilateral oophorectomy). Exposure to full doses of radiation. Use of certain drugs, especially hormonal contraceptives. Debilitating systemic diseases like Tuberculosis (TB), HIV/AIDS, or Diabetes Mellitus (DM).
• Other Causes: Tumors in the ovaries, uterus, or brain. Early onset of menopause, or it may simply be Idiopathic (having no known cause).

Diagnosis and Investigations

• Detailed history taking (asking about sudden weight changes, high stress, or the growth of excessive facial/body hair which hints at hormones) and a thorough physical examination.
• Urine test for HCG to rule out pregnancy.
• Blood tests for hormone analysis to definitively rule out hormonal imbalance.
• Ultrasound scans of the pelvis to visually inspect the pelvic cavity and its organs.
• Computerized Tomography (CT) scans to check the brain (pituitary) and pelvic organs.

Management of Amenorrhoea

The treatment approach heavily depends on the root cause and is divided into Medical, Surgical, Psychological, and Nursing care.

Medical Management

• Hormone Therapy: Prescribed to regulate levels and restore menstruation, especially in cases like Polycystic Ovary Syndrome (PCOS) or hypothalamic dysfunction.
• Medications: Progestins or combined oral contraceptives may be used to artificially induce menstruation.
• Hyperprolactinaemia Treatment: Treated by administering Bromocriptine, an ergot alkaloid drug that directly stops prolactin secretion.
• Radiotherapy: Reserved strictly for patients with tumors who fail to respond to standard medical therapy.

Surgical Management

Surgery is rare but necessary for structural issues:

• Hysteroscopic Surgery: Inserting a thin, illuminated tube (hysteroscope) through the vagina to view and cut away abnormalities like polyps or scar tissue (adhesions).
• Imperforate Hymen: Treated by a simple surgical incision and drainage. Large amounts of trapped, old blood may be released. If the membrane is very thick, a minor plastic surgery operation is required.
• Tumor or cyst removal in the reproductive organs.

Psychological Management

• Offering deep psychological counseling or referring the woman to mental health professionals to help her cope with emotional distress.
• Suggesting support groups so she can connect with other women facing similar challenges.
• Addressing body image and self-esteem. Reassure the patient that the absence of a period does not define her femininity or her worth as a woman.

Comprehensive Nursing Management

• Assessment: Conduct a comprehensive evaluation of her medical and menstrual history.
• Emotional Support: Offer empathetic, gentle, and non-judgmental support.
• Education: Teach the patient about her own reproductive anatomy, physiology, and how treatments work.
• Lifestyle Modifications: Encourage regular exercise, balanced nutrition, stress reduction techniques, and plenty of sleep to naturally regulate hormonal balance.
• Contraception Counseling: Discuss family planning options to prevent unintended pregnancies once her cycle returns.

2. Dysmenorrhoea

Dysmenorrhoea is the medical term used to describe severely painful menstrual cramps that occur just before or during the shedding of the uterine lining. Nearly 50% of all women experience some degree of pain, but about 10% are completely unable to perform their normal daily activities because the pain is so severe.

It can happen at any age but is uncommon in the first 6 months of a girl's first period and uncommon right before menopause. The most frequent sufferers are girls in their late teens and women in their early twenties.

The Core Cause

While the exact cause isn't fully understood, the severe cramping is directly linked to the release of strong chemicals called prostaglandins from the cells lining the uterus. These chemicals cause the muscular walls of the uterus to contract aggressively, leading to painful cramps and reduced blood supply to the muscle tissue.

Types of Dysmenorrhoea

A. Primary Dysmenorrhoea

This refers to painful menstruation that naturally starts a few years after puberty, where no exact underlying disease or pathology can be identified.

Predisposing Factors:

• Narrow Cervical Os (Stenosis): A very tight cervix makes it difficult for blood to flow out, causing immense tension during muscle contractions.
• Ischaemia: Reduced blood supply and oxygen to the uterine lining.
• Hormonal Imbalance: Excess prostaglandins.
• Retroverted Uterus: When the uterus tilts sharply backwards, causing physical tension on the ligaments.
• Psychological Factors: High social stress, deep fear, or anxiety about menstruation.

Signs and Symptoms:

• Lower Abdominal Pain (LAP) that ranges from mild to severe, colicky, and crampy. The pain often radiates to the lower back, thighs, and legs.
• Severe nausea and vomiting.
• Bowel changes like constipation or diarrhea.
• Fainting, heavy headaches, and general body weakness (malaise).
• Emotional irritability, nervousness, and depression.

Other Primary Management Strategies:

• Apply heat therapy (hot water bottles or heating pads) to the abdomen for relief.
• Surgical widening (dilation) of a narrow cervical canal if cervical stenosis is the main problem.
• Effective counseling, as pain can have psychological triggers. Avoid creating drug dependence.
• Encourage proper sleep, hygiene, a balanced diet, and light exercise. (Note: Getting older or delivering a baby often permanently cures the pain by naturally relaxing the uterine muscles and improving blood flow).
• Alternative therapies like hypnotherapy or acupuncture.
• Note: Dilatation and Curettage (D&C) removes dead tissue but is highly discouraged as it heavily increases the risk of severe infections.

B. Secondary Dysmenorrhoea

This refers to painful periods that start suddenly, many years after a woman has already had normal, pain-free menstrual cycles. This is pathological; upon medical investigation, a clear disease or cause is usually found.

Causes:

• Pelvic Inflammatory Disease (PID): Chronic infection of the reproductive organs.
• Uterine Fibroids: Benign tumors causing partial, painful contractions of the uterus.
• Endometriosis: The growth of endometrial tissue outside the uterus.
• Endometritis: Severe inflammation of the endometrium lining.

Additional Signs & Symptoms:

• Lower Abdominal Pain (LAP) begins much earlier—usually 3 to 4 days or even a full week before menstruation starts.
• Painful sexual intercourse (Dyspareunia).
• Inability to conceive (Infertility).
• Signs of Menorrhagia (very heavy bleeding).

Nursing Care Plan for Dysmenorrhoea

3. Menorrhagia

Menorrhagia is characterized by abnormally heavy bleeding, prolonged menstrual bleeding (lasting longer than 7 days), or a combination of both.

Causes

• Hormonal Imbalances: Sudden fluctuations in Estrogen and Progesterone disrupt the cycle, causing the lining to build up too much.
• Uterine Fibroids & Polyps: Noncancerous growths or small benign tissue polyps inside the uterus that bleed heavily.
• Adenomyosis: A painful condition where the inner lining of the uterus actually grows deep into the thick muscular wall of the uterus.
• Endometrial Hyperplasia: An abnormal, dangerous thickening of the uterine lining.
• Inherited Bleeding Disorders: Blood clotting issues like von Willebrand’s disease.
• Other Factors: Pelvic Inflammatory Disease (PID), a retroverted uterus, or serious reproductive cancers (cervical or endometrial cancer).

Signs and Symptoms

• Bleeding continuously for longer than 7 days.
• Soaking completely through one or more heavy sanitary pads every single hour for several hours in a row.
• Passing extremely large blood clots.
• Extreme fatigue, tiredness, and disruption of daily activities.
• Signs of severe anemia: Shortness of breath, rapid heart rate (tachycardia), feeling lightheaded, or dizzy.

Investigations

• Complete medical history, physical exam, and Transvaginal Ultrasound to evaluate the uterine structure.
• Blood tests: Complete blood count, iron levels, and hormone analysis.
• Coagulation Profile: Bleeding time, Prothrombin time, and Clotting time. In cases of bleeding disorders, these results will be distinctly abnormal, showing a lack of available platelets or clotting factors.
• Endometrial biopsy to rule out cancer, and a Hysteroscopy to directly look inside the lighted uterine cavity.

Management of Menorrhagia

The golden rule is to investigate and treat the exact cause.

• Medical: Give NSAIDs to reduce pain and slightly reduce bleeding. Prescribe hormonal contraceptives (pills or hormonal IUDs) to tightly regulate cycles. Give Iron supplements to restore lost iron and cure anemia.
• Surgical: Endometrial ablation (a minimally invasive procedure that destroys the lining of the uterus) or Uterine Artery Embolization (injecting small particles into the blood vessels to drastically reduce blood flow to the bleeding uterus).
• Nursing Interventions: Provide education on menstrual hygiene. Manage symptoms of pain. Offer deep emotional support for the distress caused by heavy bleeding. Encourage a healthy diet.

4. Metrorrhagia

Metrorrhagia is irregular or abnormal uterine bleeding that happens completely between normal menstrual periods. It is also defined as cyclic bleeding that occurs at normal intervals, but the bleeding is massive in amount (>80 ml) or duration. Metrorrhagia is always a warning symptom of some underlying organic or functional pathology.

Causes

• Uterine Issues: Fibroids, Adenomyosis, Uterine polyps (polyps have a vast blood supply making them bleed very easily), or a retroverted uterus causing deep pelvic congestion.
• Pelvic Endometriosis and Chronic tubo-ovarian masses.
• Cervical Erosions: The presence of a raw wound on the cervix paired with an increased blood supply results in frequent spotting/bleeding.
• Pregnancy Complications: A chronic threatened abortion, incomplete abortion, or retained pieces of placenta (which physically block the uterus from contracting tightly to seal off blood vessels).
• Molar Pregnancy (Hydatidiform Mole): An abnormal mass growing after fertilization that is supplied by thousands of tiny, fragile blood capillaries that bleed easily.
• Cancer: Malignant cancer of the cervix or endometrium.
• Hormonal: Normal ovulation bleeding or very short cycles (polymenorrhoea).

Management

Diagnosis involves a digital and speculum exam to directly visualize the cervix, pelvic scans, hormone checks, and biopsies. Treatment relies heavily on correcting the underlying cause.

• Prescribe targeted hormonal therapy (progestin or birth control pills) to regulate the cycle.
• Surgical interventions to remove polyps, fibroids, or retained placental products.
• Provide strong supportive nursing care, teaching the patient about hygiene and ensuring she comes back for critical follow-up monitoring.

5. Polymenorrhoea / Epimenorrhoea

Polymenorrhoea is a condition characterized by highly frequent menstrual periods. The periods occur at much shorter intervals than usual (between 14 and 21 days), meaning the woman bleeds every two weeks or less, though the bleeding happens at a regular, predictable pace.

Causes

• Hormonal & Glandular: Severe fluctuations in Estrogen/Progesterone, or Thyroid disorders (both hyperthyroidism and hypothyroidism affect cycle length).
• Polycystic Ovary Syndrome (PCOS): Causes hormonal chaos and enlarged ovaries filled with cysts.
• Lifestyle Factors: Chronic, immense stress, excessively heavy athletic exercise, drastic weight changes, and poor nutrition completely disrupt hormonal balance.
• Uterine Abnormalities: Fibroids, polyps, or adenomyosis.

Signs, Symptoms & Management

The patient will present with frequent bleeding, intense fatigue from constant blood loss, and severe emotional anxiety. Management involves:

• Hormone-regulating medications to physically force the cycle to lengthen back to 28 days.
• If caused by retained tissue or polyps, perform a Dilatation and Curettage (D&C) to scrape and clean the uterus.
• Strict lifestyle modifications: Ensure the patient engages in stress reduction, gets adequate sleep, and eats a nutrient-dense diet to naturally calm the hormonal system.

6. Dysfunctional Uterine Bleeding (DUB)

Dysfunctional Uterine Bleeding (DUB) is abnormal bleeding that results entirely from hormonal changes rather than from physical trauma, inflammation, pregnancy, or a tumor. It is defined as abnormal bleeding with absolutely no organic cause or underlying medical condition.

Incidence: It has a wide prevalence, but accounts for approximately 10% of patients attending outpatient gynaecology clinics.

Pathophysiology

DUB is triggered by sustained, unbroken levels of Oestrogen. This continuous Oestrogen causes the endometrium to grow incredibly thick. Because the hormones are imbalanced, this thickened lining does not shed cleanly all at once; it sheds incompletely and irregularly over long periods.

Furthermore, there is a disturbance in the delicate endometrial blood vessels, capillaries, and the local coagulation of blood. This occurs due to an alteration in the ratio of endometrial prostaglandins (which normally balance bleeding and clotting) and an incoordination in the Hypothalamo-Pituitary-Ovarian (HPO) axis.

Management Strategies

Treatment is highly customized based on the woman's age, the thickness of her uterine lining, and whether she wants to have children in the future.

• Acute Medical Stop: Heavy bleeding can be stopped quickly using high-dose oral contraceptives (COC) or Intravenous (IV) Oestrogen, followed by oral progestin. This generally stops the massive bleeding within 12 to 24 hours. Afterward, normal low-dose COCs are given for at least 3 months to stabilize the body.
• Progestin Only: If a woman cannot take Oestrogen safely, she is given Progestin-only pills for 10-14 days each month to force a clean shed of the lining.
• Fertility Goals: If the woman desperately wants to become pregnant, a drug called Clomiphene is given orally to forcefully induce ovulation and correct the hormonal axis.
• Surgical D&C: Used quickly if hormonal therapy fails to stop the bleeding.
• Total Hysterectomy: Strongly indicated if the woman is over 35 years old, her uterine lining is dangerously thick, it contains abnormal pre-cancerous cells, and she definitively does not want to become pregnant.

7. Endometriosis

Endometriosis is a severe, chronic, and incredibly painful condition where tissue that behaves exactly like the lining of the uterus (the endometrium) grows outside the uterus. This "misplaced" tissue still responds to monthly hormones—it thickens, breaks down, and bleeds inside the body cavity, causing massive inflammation and pain.

Incidence: Affects 10-15% of women between 25 and 45 years old. Alarmingly, it is found in 25-50% of all women suffering from infertility.

Common Sites of Misplaced Tissue

This stray tissue can grow almost anywhere, including: the abdominal organs, ovaries, pelvic ligaments, intestines, ureters, urinary bladder, vagina, vulva, navel, lungs, nose, conjunctiva of the eye, and rarely, on normal skin.

Causes and Predisposing Factors

• Retrograde Menstruation: The most widely accepted theory. Menstrual blood flows backwards through the fallopian tubes and spills into the open pelvic cavity, where the tissue implants and grows like a weed.
• Hormonal & Immune: Estrogen promotes the growth, while a weakened or dysfunctional immune system fails to seek out and destroy this abnormal tissue outside the uterus.
• Genetics & Race: It tends to run heavily in families (especially first-degree relatives like a mother or sister) and is more common in Caucasian women.
• Surgical Transfer: Previous surgeries involving the uterus (like C-Sections or D&C) can accidentally drag and transplant endometrial cells to surgical scars.
• Other Factors: Environmental toxins, having a retroverted uterus, or having a first baby very late in life (late primipara over 30 years old).

Signs and Symptoms

• Lower abdominal pain and extremely painful periods.
• Painful sexual intercourse (Dyspareunia).
• Infertility (due to blocked tubes and scarred ovaries).
• Pain when opening the bowels (defecating).
• Rectal Bleeding: Bleeding from the anus during menstruation because endometrial tissue has grown inside the rectum and is shedding.
• Visible bleeding from strange sites (like the nose or a surgical scar) exclusively during menstruation.
• Palpable masses and the formation of heavy scar tissue that glues organs together (Adhesions).

Diagnosis and Medical Management

Diagnosis requires a Laparoscopy to directly see the tissue, followed by a microscopic biopsy to officially confirm it. Ultrasounds, MRIs, and a blood test for the marker cell CA-125 are also utilized.

• Hormonal Suppression: The goal is to shut down the ovaries to starve the misplaced tissue. This is done using continuous COCs, heavy Progestin, or powerful GnRH agonists.
• Surgical Excision: Laparoscopic surgery to physically cut out, burn, or destroy as much of the abnormal growths as possible to restore anatomy and relieve pain.
• Total Hysterectomy: As a last resort, combined with the removal of both ovaries, when the disease destroys the pelvic organs and all other treatments fail.
• Fertility Assistance: Recommending In Vitro Fertilization (IVF) for patients desperate to bypass their scarred fallopian tubes and conceive.