Menstruation-related Diseases I Flashcards
Dr. Joda
What is menstruation?
Menstruation is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina.
What is menarche?
The initial/first menstruation cycle
What is the average age of menarche?
12 years
May occur 9 - 16 years.
What are the factors that influence the onset of menstruation?
Race
Genetics
Nutritional status
Body mass
How long does the menstrual cycle last?
Average of 28 days
May range from 21 - 35 days
How long does menstrual flow last?
Average of 5 days
May range from 3 - 7 days, but most of the bleeding occurs on days 1 and 2.
What are the components of menstrual fluid?
Endometrial cellular debris and blood.
What is the average amount of blood that is lost per menstrual cycle?
30 - 50 ml
A loss of more than ___ ml of blood is associated with anaemia.
80 ml
The menstrual cycle is regulated by the hormonal activity of _______
the hypothalamus, pituitary gland and ovary.
What are the phases involved in the ovarian and menstrual cycles?
Ovarian:
i. Follicular phase: Days 1-14. FSH stimulates the maturation of ovarian follicles, which secrete estrogen, which promotes the growth of the endometrium. One follicle matures to a Graafian follicle.
ii. Ovulatory phase: About 3 days in length. During this phase, there is an LH surge, which aids the maturation of an ovum, and the production of prostaglandins and proteolytic enzymes, which are necessary for releasing the ovum from the Graafian follicle. Levels of estradiol (estrogen) decrease during LH surge. This may cause mid-cycle endometrial bleeding.
Ovulation happens 35-44 hours after the surge begins, and releases 5 to 10ml of follicular fluid which contains the oocyte mass; this event may cause abdominal pain (mittelschmerz) for some women.
iii. Luteal phase: Lasts for about 14 days (+/- 2). After the follicle ruptures, it is referred to as the corpus luteum, which secretes progesterone, estradiol and androgens, which alter the endometrial lining; glands mature, proliferate and become secretory in nature (secretory phase) in preparation for a fertilised egg. Progesterone and estrogen levels reach their peaks in the middle of the luteal phase, whereas levels of LH and FSH decline in response to the increase in these two hormones.
Menstrual cycle
i. Proliferative phase
ii. Secretory phase
iii. Menstruation: Overlaps and occurs during days 1-5 of the follicular phase.
If pregnancy occurs, _______ released by the developing embryo supports the function of the corpus luteum.
human chorionic gonadotropin
What is dysmenorrhea?
Difficult or painful menstruation
Dysmenorrhea is divided into:
- Primary dysmenorrhea: idiopathic and associated with cramp-like abdominal pain with no identifiable pelvic disease
- secondary dysmenorrhea: associated with pelvic pathology
Dysmenorrhea usually develops within _____ months of menarche and generally affects women during their teenage years and early 20s
6-12 months
Discuss the Etiology of dysmenorrhea.
During menstruation, the endometrium and myometrium produce prostaglandins, which causes the uterus to contract and promote shedding of the endometrium. The pain felt is due to this contraction of the uterus.
Serum and endometrial prostaglandin levels are 3-4 times greater in women with dysmenorrhea than in women without it, and are highest during the first 2 days of menses, when dysmenorrhea commonly occurs.
Leukotrienes, inflammatory mediators known to cause vasoconstriction and uterine contractions, have also been found to be elevated in women with dysmenorrhea.
It has been suggested that leukotrienes may contribute significantly to dysmenorrhea in women who do not respond to therapy with prostaglandin inhibitors i.e., NSAIDS.
Discuss the pathophysiology of dysmenorrhea.
At the end of the luteal phase, progesterone levels drop, resulting in an increase in arachidonic acid, a precursor for prostaglandins (PGF2a) and leukotrienes.
Prostaglandins stimulate uterine contractions and cervical narrowing, and release vasopressin.
Leukotrienes increase the sensitivity of uterine pain fibres.
The increased levels of prostaglandins, leukotrienes and vasopressin lead to strong uterine contractions and vasoconstriction, resulting in uterine ischemia and pain.
During normal menses, contraction pressure is 50 to 80 mm Hg, each lasting about 15 to 30 seconds with a frequency of 1-4 contractions every 10 minutes
With dysmenorrhea, contraction pressure may exceed 400 mm Hg, may last longer than 90 seconds, with a frequency of 1 contraction every 15 seconds. These contribute to ischemia and tissue hypoxia and, thus, to pain.
What are the signs and symptoms of primary dysmenorrhea?
i. Pain in the mid-abdominal or suprapubic area which may radiate to the lower back and upper thighs.
ii. Nausea
iii. Vomiting
iv. Diarrhoea
v. Weakness
vi. Fatigue
vii. Dizziness
viii. Headache
ix Nervousness
x. Onset is several hours before or at the start of menses
xi. Dysmenorrhea occurs with the first 3 years after menarche, but not within the first 6 months.
What are the signs that indicate secondary dysmenorrhea?
- If dysmenorrhea appears during first several cycles (within 6 months of) or years after menarche (at 25 years or older).
- If pelvic pain occurs at times other than during menses and is not related to the first day of menses
- If the patient experiences irregular menstrual cycles, has menorrhagia (heavy flow) or a history of pelvic inflammatory disease (PID) or infertility.
Mention 5 causes of secondary dysmenorrhea.
- Endometriosis
- Pelvic inflammatory disease
- Ovarian cysts
- Benign uterine tumours
- Uterine fibroids
- Cervical stenosis
- Congenital disorders
- Intrauterine devices (IUDs)
Mention 3 conditions that cause alterations to menstrual cycling.
- amenorrhea
- menorrhagia
- dysfunctional uterine bleeding
Mention 5 non-pharmacological therapies for dysmenorrhea
- Rest
- Heat
3 Regular exercise - Massage
- Lifestyle changes e.g., cessation of smoking
What are the pharmacological therapies for dysmenorrhea?
- Analgesics
- Hormonal contraceptives
Why is Aspirin not recommended in adolescents?
Because of its association with Reye’s syndrome.
*Reye’s syndrome is an acute condition that causes swelling in the liver and brain.
