1. MENSTRUAL CONDITIONS

2. MENOPAUSE Is described as the normal physiologic cessation of menses
Marks the end of a woman’s reproductive capacity
PATHOPHYSIOLOGY/ETIOLOGY
Is caused by failing ovarian function and decreased estrogen production by the ovary
Climacteric is the transition period(perimenopausal) during which the woman’s reproductive function gradually diminishes and disappears.
Usually occurs at about age 50.

3. CLINICAL MANIFESTATIONS
______________is usually the first sign!!!
Genitalia-atrophy of vulva, vagina, urethra results in dryness, bleeding, itching, burning, dysuria, thinning of pubic hair, loss of labia minora, decreased lubrication
Sexual Function- dyspareunia, decreased intensit and duration of sexual response, but can still have active function
Vasomotor-60-70% of women experience “hot flashes”, which may be preceeded by an anxious feeling and accompanied by sweating

4. Menopause- Clinical Manifestations Con’t.
Osteoporosis- decreased bone mass results in increased hip fractures and spinal compression fractures
Cardiovascular- increased CAD, cholesterol level, and palpitations may occur
Psychological-insomnia, irritability, anxiety, memory loss, fear, and depression

5. Diagnostic Evaluation-Menopause
Hormone levels of LH and FSH will be increased
Estradiol will be decreased

6. Menopause-Treatment Estrogen replacement therapy
Indicated to reduce symptoms and to prevent osteoporosis and CAD.
Topical preparations may be used for atrophic vaginitis
Progesterone preparation also given if uterus is intact to prevent endometrial hyperplasia and possible cancer
Vaginal lubricants such as Replens to decrease vaginal dryness and dyspareunia
Vitamin E and B supplements- to decrease hot flashes
Calcium supplements to prevent bone loss
***A woman is considered post menopausal if she has not had a menstrual period for 1 year****

7. The Menstrual Cycle
Is the cyclical pattern of ovarian hormone secretion (___________and _____________) under the control of pituitary hormones(_______________ and _____________________) that results in thickening of the uterine endometrium, ovulation, and menstruation.
Cycle length varies among individuals
Phases of the Menstrual Cycle-refer to handout

8. Menstrual Cycle Diagram

9. Characteristics of Menstruation
Range
Average
Menarche(onset)
9-17 years of age
12.5 years
Cycle Length
24-32 days
29 days
Flow-duration
1-8 days
3-5 days
Flow-amount
10-75 ml
35 ml
Menopause-onset
45-55 years of age
47-50

10. Premenstrual Syndrome (PMS)
Is a group of symptoms such as headache, irritability, depression, breast tenderness, and bloating that is clearly related to the onset of menstruation
Premenstrual Dysphoric Disorder(PMDD) is a more severe form of PMS

11. Pathophysiology/ Etiology of PMS
Linked to hormonal imbalances , prostaglandins, endorphins, psychological factors such as attitudes and beliefs related to menstruation and environmental factors such as nutrition and pollution
Most common in women in their 30’s
May occur in 25 to 50% of menstruating women

12. PMS-Manifestations
Symptoms may begin 7 to 14 days before onset of menstrual flow; diminish 1 to 2 days after menses begins
Physical- edema of extremities, abdominal fullness, breast swelling and tenderness, headache, vertigo, palpitations, acne, backache, constipation, thirst, weight gain
Behavioral-irritability, fatigue, lethargy, depression, anxiety, crying spells
Diagnosis is based on clinical manifestations; usually no diagnostic evaluation is necessary

13. PMS- Management
Restrict sodium, caffeine, tobacco, ETOH, an refined sweets
Aerobic exercise
Vitamin B6 supplements and daily calcium
Progesterone replacement therapy
Prostaglandin inhibitor
Diuretics to decrease fluid retention and weight gain
Anxiolytic agents- to decrease anxiety
Counseling
Oophorectomy
usually self-limiting without complications

14. Dysmenorrhea Dysmenorrhea is painful menstruation PATHOPHYSIOLOGY-
Is classified as either primary or secondary
PRIMARY-current research supports increased prostaglandin production by the endometrium as the chief cause
SECONDARY-Due to a lesion such as endometriosis, pelvic infection, congenital abnormality, uterine fibroids

15. Dysmenorrhea-Clinical Manifestations
Pain may be due to increased uterine contractility and decreased endometrial flow
Characteristics of pain-colicky or dull, usually in lower mid-abdominal region, spasmodic or constant
May also experience nausea, vomiting, diarrhea, headache, chills, tiredness, nervousness, and low backache

16. Dysmenorrhea-Diagnostic Evaluation
Tests to rule out underlying lesion
Chlamydia and Gonorrhea tests- may show infection
Pelvic ultrasound- may detect tumor, endometriosis
Possibly a hysteroscopy and laparoscopy- primarily to detect endometriosis

17. Management of Primary Dysmenorrhea
Local heat; such as a heating pad to increase blood flow and decrease spasms
Exercise to increase endorphin release
Nonnarcotic analgesics, especially NSAID’s-ibuprofen for their antiprostaglandin action
Oral contraceptives to decrease flow and contractility of the uterus
In some cases, D & C may be helpful
Usually self-limiting without complications

18. Amenorrhea Amenorrhea is absence of menstrual flow Pathophysiology-
Classified as either Primary or Secondary
PRIMARY-
Menarche does not occur by age 16
Due to chromosomal, hormonal, nutritional, psychogenic disorders, or pregnancy

19. Amenorrhea SECONDARY-
Menstruation stops for three cycle intervals, or 6 months of amenorrhea in a woman who previously menstruated
Some medications such as phenothiazines and oral contraceptives, may also induce amenorrhea
May be due to normal pregnancy or lactation, menopause, psychogenic, hormonal, nutritional, or exercise-related disorders
Excessive exercise or inadequate nutrition with decreased body fat stores is a significant cause of amenorrhea in young women

20. Amenorrhea-Diagnostic Evaluation
Pregnancy test
Hormonal levels- LH and FSH- to detect ovarian failure
Prolactin level to rule out pituitary tumor
Progesterone challenge test
Positive-bleeding occurs-chronic anovulation is most likely
Negative-no bleeding occurs- may indicate organ failure- other tests are needed
Genetic karyotyping to detect chromosome abnormalities

21. Amenorrhea- Management
Discontinue causative medications
Hormonal replacement therapy
Nutritional, exercise, or psychological counseling as indicated
Recommend decreased exercise in athletes to increase body fat stores and decrease stress
***COMPLICATIONS- It has been theorized that prolonged amenorrhea may lead to changes of the endometrium

22. Dysfunctional Uterine Bleeding (DUB)
DUB is abnormal uterine bleeding that has no organic cause, such as tumor, infection, or pregnancy

23. DUB- Pathophysiology
DUB is frequently caused by immature hypothalmic stimulation in adolescents
DUB is caused by anovulation in any age group, especially in teens and perimenopausal women, due to impaired follicular formation or rupture, or corpus luteum dysfunction
Ovarian failure in perimenopausal women frequently causes DUB
Temporary estrogen withdrawal at ovulation may cause midcycle ovulatorry bleeding
Emotional lability, malnutrition, and changes in exercise may cause changes in gonadotropin release ar the hypothalmic level, causing altered menstrual pattern

24. DUB- Clinical Manifestations
Abnormal bleeding may occur in any of the following patterns:
Menorrhagia-excessive bleeding during regular menstruation; can be increased in duration or amount
Metorrhagia-bleeding from the uterus between regular menstrual periods; significant because it is usually a symptom of disease

25. DUB- Diagnostic Evaluation
Tests are done to rule out pathologic causes of abnormal bleeding
Pregnancy test
CBC to detect anemia and platelet count and coagulation screen to rule out blood dyscrasia
PAP smear to rule out malignancy
Thorough exam to rule out trauma or foreign body
Chlamydia and gonorrhea test to rule out PID
Pelvic ultrasound to rule out ovarian and uterine cysts and tumors
Hysteroscopy to detect uterine fibroids, polyps, and other lesions
Endometrial biopsy to determine hormonal effect on uterus and rule out malignancy
Laparoscopy to evaluate for endometriosis

26. DUB- Management
Treat underlying anemia with iron, possible transfusions
Progesterone therapy to stop acute bleeding
Oral contraceptives to control chronic bleeding
Androgen therapy with danazol(Danocrine) to reduce menstrual blood loss by supressing the action of the anterior pituitary
Dilation and curettage