1. Menstruation and Vaginal Bleeding
Dr. Miada Mahmoud Rady
EMS/473
Gynecological emergencies lecture 2

2. Menstrual cycles
Menstruation: the cyclic and periodic discharge of 25 to 65 mL of blood, epithelial cells, mucus, and endometrial tissue that normally lasts from 2-7 days and recurs every 21-35days (28+/-7 days).
So the average duration of menstrual blood flow is 2-7 days.
Menstruation normally occur every days.
Menarche: the onset of first menstruation and it typically occur between years of age.

3. Systemic Changes During Menstrual Cycle
Weight gain due to salt and water retention.
Increased muscle tonicity and susceptibility to bruising.
Breast pain and tenderness resulting from swelling
Headache including menstrual migraine ( vascular headache resulting from the hormonal changes.
Severe cramping.
Emotional changes e.g. Irritability and depression.

4. Premenstrual Syndrome
Also known as PMS .
Definition : cluster of symptoms that occurs about 7-14days before the onset of menstrual flow and generally subsides once the flow begins.
It commonly affects premenopausal females (30-40years old).
Clinical presentation include both physical and emotional symptoms.

5. Clinical Presentation of PMS
Emotional
Physical
Tension or anxiety.
Crying spells.
Mood swings.
Appetite changes.
Trouble falling asleep .
Social withdrawal.
Poor concentration.
Joint or muscle pain.
Headache and Fatigue.
Weight gain.
Abdominal bloating.
Breast tenderness.
Acne flare-ups.
Constipation or diarrhea.

6. Clinical Presentation of PMS
Symptoms can be exacerbated by :
Stress.
Diet.
Alcohol consumption.
drug use.
Emergency presentation of PMS : reactive hypoglycemia, resulting in increased fatigue.

7. Premenstrual Tension Syndrome
Prehospital treatment :
Mainly supportive including :
Administration of oral or IV glucose if glucose levels support.
Administration of a small dose of analgesics or anxiolytics to reduce patient anxiety .

8. Mittelschmerz
Definition : mid cyclic abdominal pain and cramping that occurs at any time during ovulation usually 2 weeks before the menstrual flow.

9. Criteria of the pain
midcyclic, with a history of similar pain episodes during previous periods.
Not sever (usually mild).
Not referred or radiated.
Localized to one side , pain may be reported as "switching sides" from month to month.
Associated with mild nausea and vaginal spotting.
Relieved by over the counter analgesic.

10. Management Assurance and mild analgesics
Any persistent or sever pain or associated abnormal symptoms ( vomiting , diarrhea , fever or abdominal tenderness ) , should be evaluated by a physician.

11. Dysmenorrhea Definition : painful menstruation .
There are two types of dysmenorrhoea :
Primary dysmenorrhoea .
Secondary dysmenorrhoea .

12. Primary dysmenorrhoea
No underlying pathology ( functional ).
Occurs at the beginning of menstrual blood flow and lasts for the first 2 days .
Associated with nausea, vomiting, and diarrhea .
Management :
Assurance .
Bed rest .
Simple analgesics.

13. Secondary dysmenorrhoea
May signal an underlying pathology.
Present before, during, and after the menstrual flow.
Causes of secondary dysmenorrhoea:
Uterine fibroid.
Endometriosis.
Pelvic inflammatory disease.
Chronic pelvic congestion.
Intra uterine device.

14. Menopause
Definition : last menstrual cycle which marks the end of childbearing age.
Typically begins between the ages of 40 and 50.
The menstrual cycles become less frequent over time and then stops completely .

15. Clinical Presentation of Menopause
Diaphoresis ( excessive sweating ).
Hair loss.
Hot flashes (sometimes accompanied by tachycardia).
Severe muscle aches and pains.
Headache and Vertigo.
Dyspnea.
Digestive problems.
Emotional instability.

16. Complication of menopause
Atherosclerosis.
Osteoporosis.
Coronary heart disease.
Atrophy of genitourinary organs which result in :
Vaginal dryness and discomfort.
Urinary frequency.
Nocturia.
Incontinence.

17. Menopause

18. Management
Hormone replacement therapy.
Calcium .
Multivitamins .

19. Vaginal bleeding
Vaginal bleeding or dysfunctional uterine bleeding is one of the most frequent reasons that women consult a gynecologist.
Hypermenorrhea : Flow of blood lasts several days longer than normal or is excessive.
Polymenorrhea: Blood flow occurs more often than a 24-day interval.
Metrorrhagia: Blood flow or intermittent spotting occurring irregularly but frequently

20. Causes of vaginal bleeding
Trauma : rape , accident or during sexual intercourse.
Infection : vaginitis , cervicitis and endometritis.
Tumor : vaginal , cervical or uterine cancer .
Specific diseases : ovarian cyst , polycystic ovarian disease and endometriosis.
Systemic disease : thyroid disease and bleeding disorders.
Obstetric causes of vaginal bleeding : abortion , ectopic pregnancy , abruptioplacenta and placenta praevia.

21. Assessment Stress Points
History :
Find out if there is any possibility of pregnancy ,(LNMP).
Include questions about any incidents or events that led up to the patient requesting EMS.
Determine the amount of blood loss.
Determine if the patient has any pain or discharge associated with the bleeding.
Determine if the patient uses contraception and what kind.

22. Indicators of Sever Bleeding From History
Quantity .
Color : bright red indicates sever bleeding .
Associated clots : clots indicates sever bleeding.
Duration .
Associated symptoms : weakness , fainting and collapse.

23. Assessment Stress Points
Examination : if history suggests significant bleeding , assess for signs and symptoms of hypovolemic shock :
Orthostatic hypotension (first sign)
Resting tachycardia
Hypotension.
Finally shock .

24. Management
Maintain patent air way , if any signs of shock is present give high-flow oxygen.
Keep the patient warm.
Provide IV fluid therapy.
If the bleeding is severe, apply dressings to the vaginal area.
Maintain professionalism and empathy

25. Amenorrhea Definition : Amenorrhea is the absence of menses.
There are two types :
Primary amenorrhea : primary amenorrhea is the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics.
Secondary amenorrhea : cessation of previously existing menstruation after menarche has started .

26. Causes of secondary amenorrhea
Pregnancy (most common cause)
Exercise
Drop of body fat below a certain percentage
Emotional problems or extreme stress
Anorexia nervosa

27. Home work Enumerate : Clinical Presentation of PMS .
Criteria of the Mittelschmerz pain .
Differentiate in table between primary and secondry dysmenorrhoea ??
home work has to be sent to the in ward format one day before next week lecture .

28. Any questions ???