MENSTRUALDISORDERS

DR HEBA AHMED OSMAN

ASSISTANT PROFESSOR OF MATERNITY NURSING
NORTHERN BORDER UNIVERSITY
 MENSTRUALDISORDERS

Upon completion of the chapter, the learner will be able to:

1. Define the key terms used in this chapter.
2. Examine common reproductive concerns in terms of symptoms, diagnostic tests, and
appropriate interventions.
3. Identify risk factors and outline appropriate client education needed in common
reproductive disorders.
4. 5. Explain the physiologic and psychological aspects of menopause.
6. Delineate the nursing management needed for women experiencing common
reproductive disorders.
 MENSTRUAL CYCLE DISORDERS
The four most common menstrual cycle
disorders are:

1) Amenorrhea
i

2) Abnormal uterine bleeding

3) Pain associated with the menstrual cycle

4) Cyclic mood changes, including

premenstrual syndrome (PMS).
 AMENORRHEA
Amenorrhea is absence of menses. It can Abnormal amenorrhea :

indicate either normal physiologic processes Two types , primary amenorrhea and secondary

or pathology in the reproductive system amenorrhea

Normal amenorrhea occur through :-  Primary amenorrhea is defined as either:

1. Prepubertal ( before menarche (onset of 1. Absence of menses by age 14 , with absence of growth

and development of secondary sexual

menstruation )
characteristics or
2. Pregnancy
2. Absence of menses by age 16, with normal
l
3. During the puerperium development of secondary sexual characteristics

 Secondary amenorrhea is defined as :-

4. Postmenopausal females.
Is the absence of menses for three cycles or 6 months in
5. lactation
women who have previously menstruated regularly.
ETIOLOGY AND MANAGEMENT OF PRIMARY AMENORRHEA

causes of primary amenorrhea:

Management of primary amenorrhea:
1. low body weight for height 1. Pregnancy test to insure that
woman pregnant or not
2. Eating disorders (anorexia nervosa)
2. Reducing excessive exercise to allow
X weight gain.
adequate
3. Chronic stress
X 3. Counseling for eating disorders, such
4. Hypothyroidism as anorexia nervosa.

5. Abnormal steroid secretion 4. Psychological support

5. Hormone therapy may establish
6. Central nervous system diseases normal menses if the cause is
hormone imbalance.
7. Drug use (therapeutic or illicit)

8. Obesity is often associated with insulin

resistance and chronic anovulation
ETIOLOGY AND MANAGEMENT OF SECONDARY AMENORRHEA

causes of secondary amenorrhea:

Management of secondary amenorrhea:
1. Diabetes mellitus
1. Pregnancy test to insure that woman pregnant or
2. Tuberculosis not.

3. Hypothyroidism 2. Treatment of anovulation.

4. Central nervous system lesions 3. Testing levels of hormones related to the menstrual

5. Hormonal imbalances cycle, to improve timing of the cycle, anovulation,

and identification of other abnormalities .
6. Aerobic exercise
4. Treatment of poly cystic ovary (PCOS): excess
7. Poor nutrition
androgen levels may cause polycystic ovary
8. Use of hormonal contraceptives syndrome characterized by acne and excess weight

9. Ovarian tumors and body hair, as well as the anovulation that

results in amenorrhea.
 NURSING CONSIDERATION
1. Taking history : medical history, obstetric history, eating habits, current
exercise pattern.

2. Emotional support is essential to evaluate the cause of absent menses.

3. Teaching includes the importance of adequate nutrition

and discouragement of rigorous dieting.

4. The nurse should explain that excessive aerobic training can cause
amenorrhea.

5. Effective weight control may reduce factors

related to PCOS

6. Psychological counseling
 ABNORMAL UTERINE BLEEDING
Definition:-
Bleeding that occurs with no identifiable pathology, it
affects 33% to 50% , associated with anovulatory cycles,
which are common for the first year after menarche and
later in life as women approach menopause.
Types :
 (Menorrhagia)); prolonged or heavy bleeding
 (Metrorrhagia);bleeding that occurs irregularly and often

l
between menstrual periods
(Menometrorrhagia), bleeding that occurs irregularly and
more frequently
 ABNORMAL UTERINE BLEEDING
Causes:
1. Pregnancy complications, such as spontaneous
abortion.
2. Anatomic lesions, either benign or malignant, of
the vagina, cervix, or uterus.
3. Drug-induced bleeding, such as breakthrough
bleeding that may occur in women taking hormonal
contraceptives.
4. Systemic disorders, such as diabetes mellitus,
uterine myomas (fibroids), and hypothyroidism.
5. Failure to ovulate.
 MANAGEMENT
Investegtiotion
1) Sensitive pregnancy test, coagulation studies, and tests to determine whether ovulation is occurring.

2) Liver function tests, tests to determine anemic

3) Ultrasonography or hysteroscopy may be used to look for polyps and check the condition of the uterine
lining.

Medical treatment
 Hormonal treatment is progestin-estrogen combination ,oral contraceptives that suppress ovulation and
allow a more stable endometrial lining to form.
 Surgical therapy may include dilation and curettage (D&C) to remove polyps or to diagnose endometrial
hyperplasia
X
 Hysterectomy may be performed if the uterus is enlarged as a result of fibroids or adenomyosis (benign
invasive growth of the endometrium into the muscular layer of the uterus) and if the woman does not want
more children.
 Laser ablation may be used to permanently remove the endometrial lining without hysterectomy
 Treatment of iron deficiency anemia as a result of bleeding
 NURSING CONSIDERATIONS
1) Encourage women to seek medical attention when irregular or prolonged bleeding
occurs.

2) Help the woman keep a record of the bleeding episodes and the amount of blood
lost.

3) Teaches the importance of adequate nutrition and discourages rigorous dieting. For
women who are concerned about amenorrhea,

4) Teaches methods to reduce stress and promote relaxation.

5) Provide support for women who fear that irregular bleeding indicates a serious
disease, such as cancer.

6) Provide information about diagnostic procedures, such as pelvic examination,

the Pap test, and other tests, is helpful.
 Cyclic Pelvic Pain
 Cyclic pelvic pain must be distinguished from acute pelvic pain. Acute pelvic pain is
sudden in onset and is not experienced with each menstrual cycle. It may indicate
a serious disorder, such as ectopic pregnancy or appendicitis.

 Cyclic pelvic pain occurs repetitively and predictably in a specific phase of the
menstrual cycle.

Causes of cyclic pelvic pain

 Mittelschmerz (“middle” pain)

 Primary dysmenorrhea (painful menstruation)

 Secondary dysmenorrhea, or pelvic pain that is not cyclic, is usually related to

pelvic pathology.

 Endometriosis (tissue resembling endometrium outside uterine cavity).

 Mittelschmerz (“middle” pain)
Definition:
 Mittelschmerz ( middle”
“ pain) is pelvic pain that occurs midway between
menstrual periods at the time of ovulation.

 Causes :
x̅
 Growth of the dominant follicle within the ovary
 Rupture of the follicle and subsequent spillage of follicular fluid and blood into the
peritoneal space.

 S&S:
 The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally
lasts from a few hours to 2 days
 slight vaginal bleeding may accompany the discomfort.

 TTT:
 Generally, women do not need medical treatment beyond simple explanation of
the discomfort or mild analgesics..
 Dysmenorrhea (cramps)
Definition :-

 Primary dysmenorrhea is menstrual pain without identified pathology. Its onset is usually 1 to 3 years after
menstruation begins, when ovulatory menstrual cycles are well established, and it is most common in young,
nulliparous women.

S & S:-

 The pain (cramp ) begins within hours of the onset of menses, and it is spasmodic or colicky in nature because of
increased prostaglandins secreted at this time
 The duration of the pain is usually 48 to 72 hours.
 Felt in the lower abdomen but often radiates to the lower back or down the legs.
 Nausea, vomiting, loose stools, or dizziness may also occur.

TTT:-
 Oral contraceptives decrease the amount of endometrial growth then decrease release of prostaglandin
 Prostaglandin inhibitors(nonsteroidal anti-inflammatory drugs) such as ibuprofen To be effective should be taken
around the clock for at least 48 to 72 hours beginning when menstrual flow starts.
 Endometriosis
Detention :-
The presence of endometrium outside the uterus. Most
women with endometriosis are in their 30s and nulli-
parous, and many have had infertility problems.

Incidence:

About 10%, the actual unknown

X
Sites:- Attached to
 Ovaries.

 Fallopian tubes.

 The small intestine or large intestine.

 The broad , round l, uterosacral ligament .

 Uterovesical fold.

 Cul-de- sac
 Endometrioses (cont.)
Causes and pathophysiology
The cause remains unknown. One theory is that endometrial cells are transported from the uterine cavity during
menstruation and subsequently attach to nearby structures and proliferate, creating spots of endometrial tissue

S&S
1. Cyclic pain and infertility

2. Endometriosis pain is deep, unilateral or bilateral, and either sharp or dull.

3. Dyspareunia (painful intercourse) may occur.

4. Rectal pain may occur during defecation.

5. Diarrhea, constipation, and sensations of rectal pressure or urgency

TTT
 Treatment may be either medical or surgical. A Continuous oral contraceptives for 6 to 12 months suppress
endometrial tissue proliferation, particularly in a woman who desires pregnancy
 Nursing considerations ( Nurse role )

The nurse should suggest nonpharmacologic pain-relief measures , such as:-

 Frequent rest periods.

 Application of heat to the lower abdomen, relaxation technique .

X

 Moderate exercise.

 A well-balanced diet.

 Avoid stress-provoking situations during the menstrual period if possible.

 Counsel the woman about expected effects of prescribed medication and side or adverse

effects.
 Premenstrual Syndrome(PMS)

Definition

 (PMS) is a minor physical and emotional changes

related to women menstrual cycles. PMS, also called
premenstrual dysphoric disorder (PMDD), affects about
5% to 10% of women , severely enough to cause
significant disruption with their daily lives

Causes

 Hormonal imbalance that results from natural

fluctuations in the menstrual cycle.

 Stress

 Nutrient deficiencies.

 Diet :excessive sodium, alcohol, and caffeine.

 Symptoms of (PMS)

Physical Symptoms Behavioural Symptoms

1. Headaches, dizziness
1. Depressed mood
2. Abdominal bloating or swelling; swelling of the
2. Feelings of hopelessness
extremities
3. Marked anxiety
3. Breast tenderness xx
4. Confusion, forgetfulness, poor
4. Hot flashes
concentration
5. Abdominal cramps
5. Irritability and anger
6. Generalized muscle and joint pain
6. Emotional lability: tearfulness or readiness
7. Fatigue to cry, loneliness, mood
8. Appetite changes: binge eating, cravings 7. Instability
9. Sleep changes: excessive sleep or insomnia 8. Reduced interest in activities of living
10. Reduced sexual interest 9. Social avoidance

10. Lethargy or high energy

 Measures to Relieve Symptoms of(PMS)
Stress Management

 During the time when there are no symptoms of PMS, acknowledge the effect of PMS on daily life and make

plans to avoid stressful situations during the premenstrual period when symptoms are acute.

 Use guided imagery, conscious relaxation techniques, warm baths, and massage to reduce stress.

Sleep and Rest

To reduce fatigue and combat insomnia:

 Adhere to a regular schedule for sleep.X

 Drink a glass of milk to promote sleep before bedtime.

 Schedule exercise in the morning or early afternoon rather than late afternoon.

 Engage in relaxing activities, such as reading, before bedtime, and avoid excitement at this time.

Exercise

 Increase physical exercise to relieve tension and to decrease depression. Aerobic activity, such as jogging or walking, several times a

week is recommended.
 Measures to Relieve Symptoms of(PMS)
cont.
Diet
 Decrease consumption of caffeine (coffee, tea, colas, chocolate), which
increases irritability, insomnia, anxiety, and nervousness.

 Avoid simple sugars (cookies, cake, candy) to prevent high blood glucose
levels followed by a rapid decline and a period of low blood glucose levels
(hypoglycaemia).

 Decrease intake of salty foods (chips, pickles) to reduce fluid retention.

 Drink at least 2000 mL (2 quarts) of water per day, and do not include
other beverages in this total.

 Eat six small meals a day to prevent hypoglycemia. Meals should be well
balanced, with emphasis on fresh fruits and vegetables, complex
carbohydrates, and non fat milk products.

 Avoid alcohol, which aggravates depression

 Infertility
Definition

Fertility: - Means ability to conceive (to get pregnancy)

Infertility: is the inability to conceive after 1 year of unprotected, regular sexual intercourse
unprotected by contraception..
Sterility: Absolute condition is an inability of a man to fertilize an egg, or reproduce.
Types of infertility
 Primary infertility: Which mean woman have never conceived.
 Secondary infertility: Couples may have conceived before but are unable to conceive again .
About one in six couples of reproductive age cannot have a baby when they desire
 Factor contributing to infertility
About one third of infertility cases are male factor, one third are
female factor, and one third are a combination of the two
Male factor
1) Abnormalities of the Sperm
2) Abnormal Erections
3) Abnormal Ejaculation
4) Abnormalities of Seminal Fluid
 Abnormalities of the sperm
1) Abnormalities of the sperm
The average number of sperm released at ejaculation is 35 million to
200 million
Factors that can impair the number and function of the sperm include
following:
É
 Genetic disorder.(hypospadias)
 Azoospermia (sperm absent in semen)
 Oligospermia (decreased sperm in semen)
• Anatomic abnormalities such as a varicocele or obstruction of the
ducts that carry sperm to the penis
• Exposure to toxins such as lead, pesticides, or other chemicals
 Factors that can impair the number and function
of the sperm include following (cont.)
• Abnormal sperm structure or movement

• Acute or chronic illness such as mumps, cirrhosis, or renal failure

• Infections of the genital tract

• Therapeutic treatments such as antineoplastic drugs or radiation for cancer

• Radiation

• Excessive alcohol intake

• Use of drugs such as marijuana or cocaine

• An elevated scrotal temperature resulting from febrile illness, repeated use of saunas or hot
tubs, or sitting for prolonged periods of time

• Immunologic factors, produced by the man against his own sperm (autoantibodies) or by
the woman, causing the sperm to clump or be unable to penetrate the ovum
 2) Abnormal Erections
Abnormal erections reduce the man’s ability to , deposit sperm-bearing seminal fluid in the
woman’s upper vagina.
Erections are influenced by
 Physical and psychological factors.

 Central nervous system dysfunction, which may be caused by drugs

 Psychiatric disturbance, or chronic illness, can interfere with erections.

 Surgery and disorders affecting the spinal cord or the autonomic nervous system also may
disrupt normal erections.

 Peripheral vascular disease reduces the amount of blood entering the penis and thereby
reduces the ability to maintain an erection.

 Drugs such as antihypertensives or antidepressants may reduce the erection or shorten its
duration
 3) Abnormal Ejaculation
in
Abnormal ejaculation : prevents deposition of the sperm in the ideal place to achieve pregnancy.

Retrograde ejaculation: is the release of semen backward into the bladder rather than forward through the tip of the penis.

Conditions that may cause retrograde ejaculation are

 Diabetes, neurologic disorders, surgery that impairs function of the sympathetic nerves, and drugs such as
antihypertensives and psychotropics.

 Men who have suffered spinal cord injury may retain the ability to ejaculate, depending on the level of cord damage.

 Anatomic abnormalities such as hypospadias (urethral opening on the underside of the penis) may cause deposition of
semen near the vaginal outlet rather than near the cervix.

 Excessive alcohol intake or use of some therapeutic or illicit drugs can adversely affect ejaculation as well as sperm
number and function.

 Ejaculation may be slow, absent, or retrograde when a man takes drugs that affect neurologic coordination of this event.

 Premature ejaculation is usually related to psychological disorders such as performance , anxiety or unresolved conflicts.
 4) Abnormalities of Seminal Fluid

 The seminal fluid nourishes, protects, and carries sperm into the vagina

until they enter the cervix. Only sperm enter the cervix; the seminal fluid

remains in the vagina. Semen coagulates immediately after ejaculation

but liquefies within 60 minutes, permitting forward movement of sperm.

 Seminal fluid that remains thick traps the sperm, impeding their

movement into the cervix. The pH of seminal fluid is slightly alkaline to

protect the sperm from the acidic secretions of the vagina.

 Causes of abnormality in semen fluid

 Obstruction or infection in a specific area of the genital tract.

 Seminal fluid that is abnormal in amount, consistency, or

chemical composition suggests obstruction, inflammation,or

infection.

 The presence of large numbers of leukocytes suggests

infection.
 Woman Factors
1. Disorder of Ovulation

2. Abnormalities of the Fallopian Tubes

3. Abnormalities of the Cervix or Uterus

Disorders of Ovulation
Ovulation can be disrupted by many factors, including the following:-

 A dysfunction in the hypothalamus or pituitary gland that alters the secretion of GnRH, FSH, and LH

 Failure of the ovaries to respond to FSH and LH stimulation, preventing maturation and release of the ovum

 Poly cystic ovary

● Tumors ,Stress, Obesity , Anorexia, Systemic disease
● Abnormalities in the ovaries or other endocrine glands
● Cancer , chemotherapeutic agents, excessive alcohol intake, and cigarette smoking.

●
 Abnormalities of the Fallopian Tubes

Vp At least one open fallopian tube is needed for natural conception and implantation to occur.

 Tubal obstruction may occur because of scarring and adhesions after reproductive tract infections.

 Tubal obstruction (after pelvic surgery, ruptured appendix, peritonitis, or ovarian cysts)

 Infections such as chlamydia, gonorrhea, and other sexually transmissible diseases (STDs) are
responsible for many cases of infertility from tubal obstruction.

 Endometriosis

 Congenital anomalies
 3) Abnormalities of the Cervix or Uterus
 Cervical Polyps or scarring
 Stenosis or congenital malformations of the

 Abnormal cervical mucus caused by estrogen cervix or uterine cavity may cause repeated
deficiency loss of a normal embryo or fetus

 Surgical destruction x of the mucus-secreting

 hysterectomy also may occur after surgery
glands
or trauma from a previous birth
 Cervical damage secondary to infection
 Uterine myomas(benign tumors of the
 Repeated Pregnancy Loss
uterine muscle) and adhesions inside the

 Abnormalities of the Fetal Chromosomes uterine cavity may cause repeated fetal

 fetal chromosomes may result in spontaneous losses.

abortion, usually in the first trimester.

 Diagnostic Tests

 Early evaluation for both partners may include the following:

 • Ovulation monitoring kit to identify if ovulation has occurred

 • Evaluation of the cervical mucus to identify changes that occur with ovulation
• Hormone evaluations such as estrogen, progesterone, LH, FSH, thyroid function

 • Ultrasound imaging of internal reproductive organs

 • Radiographic imaging to visualize the uterine cavity and fallopian tubes

 • Semen analysis

 • Testicular biopsy
 Diagnostic Tests(Male)
 Semen Analysis
 Evaluates structure and function of sperm and composition of seminal fluid.
 Semen volume: 2 mL or more. pH: 7.2-7.8. Sperm concentration: 20 million/mL or more. Motility: 50% or more
with normal forms. Morphology: 30% or more with normal forms. Viability: 50% or more live. Liquefaction:
within 30 min. Leukocytes (white blood cells): fewer than 1 million/mL.
 Endocrine Tests
K
 Evaluate function of hypothalamus, pituitary gland, and response of testicles. determine testosterone,
luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels.

 Ultrasonography

 Evaluates structure of prostate gland, seminal vesicles, and ejaculatory ducts by use of a transrectal probe.

 Testicular Biopsy

 An invasive test for obtaining a sample of testicular tissue; identifies pathology and obstructions.

 Sperm Penetration Assay

 Female

 Ovulation Prediction Identifies the surge of LH, which precedes ovulation by 24 to

36 hr.

 Basal body temperature (BBT), or temperature at rest, may be used to identify if

ovulation has occurred and the timing of intercourse in relation to probable

ovulation.

 Ultrasonography

 Evaluates structure of pelvic organs. Evaluates cyclic endometrial changes.

Identifies ovarian follicles and release of ova at ovulation.

 Evaluates for presence of ectopic or multifetal pregnancy.

 Female
 Hysterosalpingogram (HSG)

 Gentle injection of contrast medium into the

cervix while imaging the pelvis to visualize
passage of the dye through the uterus and
fallopian
F tubes.

 Postcoital Test

 Evaluates characteristics of cervical mucus and sperm function within that mucus at time of

ovulation.

 Ultrasonography ensures proper timing for test

 Infertility treatment
General

 Both members of the couple are evaluated systematically to identify the most time- and cost-effective therapy.

 Simpler evaluations and therapies are done before more complex efforts are undertaken.

 A complete medical history is taken and physical examination performed for each partner.

 The ages of the partners, particularly the woman’s, are considered. Evaluations and therapy proceed more quickly
if the woman is in her mid 30s or older.

 Costs may be partially covered by insurance; check to see what your insurance covers.

 Difficult decisions may be required at different times during evaluation and treatment. Decisions might include
whether to proceed to more complex and expensive tests and therapies, whether to take a break from treatment,
or whether to abandon treatment altogether.

 Infertility treatment can be stressful, can occupy many hours per week, and requires a substantial commitment to
self-care.
 Infertility treatment(cont.)

Men

 Semen analysis is usually the first test. Several semen specimens are obtained over

several weeks for the best evaluation.

 Depending on the man’s medical history, physical examination findings, and semen

analysis, other diagnostic tests may be done (hormone assay, an ultrasound of the

reproductive organs, a biopsy of the testicles, and specialized tests of sperm function).

 Corrective measures may include medications, surgery, and methods to reduce the

scrotal temperature.
 Women
 The first evaluation is usually to determine whether the woman is ovulating each
month or not.

 Self-assessment of basal body temperature and cervical mucus may also be taught.

 These assessments are often done at the same time as other tests.

 Other common evaluations include ultrasound or x-ray imaging of the uterus and the
fallopian tubes to determine their patency.

 For some tests and therapies, an operative procedure is required (e.g., hysteroscopy,
laparoscopy, laser surgery, and microsurgery).

 Corrective measures depend on the problem identified. Examples include

medications, surgery, and advanced reproductive techniques, such as in vitro
fertilization.
 Treatment for infertility

 Bromocriptine (Parlodel) Corrects excess prolactin secretion by anterior pituitary

 Chorionic gonadotropin, human Clomiphene citrate (Clomid) Letrozole (Femara)

 Used in conjunction with gonadotropins to stimulate ovulation in the female or

sperm formation in the male.

 FSH, recombinant Stimulation of ovarian follicle growth

 GnRH antagonists to REDUCE ENDOMETRIOSIS

 Treatment for infertility

 GnRH agonists Stimulates release of FSH and LH from the pituitary gland in men and

women who have deficient GnRH secretion by their hypothalamus

 Progesterone Luteal phase support; prepares uterine lining and promotes implantation of

embryo.

 Erectile agents vardenafil [Levitra])Increase blood flow to the penis, improving erectile

function
 Assisted reproductive technologies

 In vitro fertilization (IVF)

 Gamete intrafallopian transfer (GIFT)

 Intracytoplasmic sperm injection (ICSI)

 Donor oocytes or sperm

 Gestational carrier (surrogacy)

 To In vitro fertilization (IVF)

 Oocytes are fertilized in the lab and

transferred to the uterus.

Nurse responsibility :

 Nurse advises woman to take medication to stimulate ovulation so

the mature ovum can be retrieved by needle aspiration.
 Gamete intrafallopian transfer (GIFT)

 Oocytes and sperm are combined and

immediately placed in the fallopian
tube so fertilization can occur
naturally.
E

 Nurse responsibility :
 Nurse needs to inform couple of risks
and have consent signed
 w̅Intracytoplasmic sperm injection (ICSI)

 One sperm is injected into the

cytoplasm of the oocyte to
fertilize it.

Nurse responsibility :

 Nurse needs to inform the male

that sperm will be aspirated by a
needle through the skin into the
epididymis.
References

 Sharon Smith Murry Emily Slone McKinney, (2014) Foundations of maternal newborn and
women health nursing 6th edition page no-328-349

 Robert Durham, Linda Chapman, (2014): Maternal-New-born Nursing: The Critical

Components of Nursing Care, 2nd ed., F.A Davis Company, USA-

 Shannon E. Perry, Marilyn J. Hockenberry, Deitra Leonard Lowdermilk, David Wilson (2014):
Maternal & Child Nursing Care, Mosby & Elsevier Inc., Canada

 Susan Scott Ricci ,( 2009) : Essentials Of Maternity, newborn, & Women's health Nursing
Second Edition Page No 419-444 www.google. Com