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MENSTRUAL DISORDERS

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ABNORMAl MENSTRUATION ? Menorrhagia (hypermenorrhea): uterine bleeding excessive in both amount and duration of flow, but occurring at regular intervals. ? Oligomenorrhea: menstrual periods at intervals of more than 35 days. ? Menometrorrhagia: uterine bleeding usually excessive and prolonged occurring at frequent and irregular intervals. ? Polymenorrhea: frequent but regular episodes of uterine bleeding occurring at intervals of 21 days or less. ? Metrorrhagia: uterine bleeding occurring at irregular intervals. ? Hypomenorrhea: uterine bleeding that is regular but decreased in amount. ? Intermenstrual bleeding: uterine bleeding, usually not excessive, occurring at any time during the menstrual cycle other than during normal menstruation.
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MENSTRUAL
DISORDERS
DR GREGORY HALLE
Gynaecologist - Obstetrician
General Hospital Douala
Postgraduate Training in Reproductive Health Research
Faculty of Medicine, University of Yaoundé 2007

NORMAL MENSTRUATION
? Cyle length: marked variability in women not using
oral contraceptives.
? 5th-95th centile being 23 – 39.4 days.
? Mean duration 29.6 days.
? Cycle length decreases with advancing age.
? Abnormal menstruation: bleeding at any time outside
normal menstruation and any variation outside the
defined limits.
? Acyclical bleeding – pre or postmenopausal bleeding.

NORMAL MENSTRUATION
? Duration of menstrual blood loss: 2-7 days, mean of 5
days.
? Excessive menstruation >7 days.
? Blood loss: difficult to evaluate.
? Racial differences.
? Average blood loss 40cc: 90% occurs 1-3 days.
? Pathological >80cc.
? Critical appraisal of menstrual blood loss is uncertain
because of underestimation by some patients.

NORMAL MENSTRUATION
?
50–75% of menstrual flow is blood, the rest is made up of
fragments of endometrial tissue and mucus.
?
Menstrual blood does not clot – Aggregation of endometrial
tissue, red blood cells, degenerated platelets and fibrin.
?
Endometrium contains large amounts of fibrin degradation
products.
?
When blood loss is excessive, lytic substances that are rapidly
consumed lead to the presence of clots in menstrual flow –
Excessive menstrual blood flow.

NORMAL MENSTRUATION
ROLE OF EICOSANOIDS
?
Prostanoids are not stored but are synthesized in tissues as required.
?
Prostaglandins PGF2alpha , PGE2, prostacylin(PGI2), thromboxane(TxA2)
and leukotrienes all play an important role in menstruation.
?
Phospholipids are released from cell membranes and converted to
arachidonic acid by phospholipase A2. Cyclo-oxygenase converts
arachidonic acid to unstable endoperoxides (PGG3 and PGH2) which are
rapidly converted to by specific synthetases into:
?
PG2 alpha - potent vasoconstrictor and weakly platelet antiaggregatory.
?
PGI2 – potent vaso-dilator and weakly platelet antiaggregatory.
?
PGD2 – platelet aggregation inhibitor.
?
Thromboxane – potent vasoconstrictor and platelet inhibitor.
?
Prostanoids are thought to act at their site of synthesis.

ABNORMAl MENSTRUATION
?
Menorrhagia (hypermenorrhea): uterine bleeding excessive in both amount
and duration of flow, but occurring at regular intervals.
?
Oligomenorrhea: menstrual periods at intervals of more than 35 days.
?
Menometrorrhagia: uterine bleeding usually excessive and prolonged
occurring at frequent and irregular intervals.
?
Polymenorrhea: frequent but regular episodes of uterine bleeding occurring
at intervals of 21 days or less.
?
Metrorrhagia: uterine bleeding occurring at irregular intervals.
?
Hypomenorrhea: uterine bleeding that is regular but decreased in amount.
?
Intermenstrual bleeding: uterine bleeding, usually not excessive, occurring
at any time during the menstrual cycle other than during normal
menstruation.

Dysfunctional uterine bleeding
(anovulatory bleeding)
? Blood flow is usually excessive in duration, amount
and frequency.
? More common during the perimenarcheal and
perimenopausal years.
? Usually episodes are transient and self limiting.
? During the reproductive years many factors might
disrupt and interrupt ovulation.
? Causes for disturbed function can be central,
intermediate, end organ, and physiologic.

Etiologic classification of
anovulatory bleeding
?
Central causes: immaturity of the hypothalamic-pituitary axis; functional or
chronic diseases; traumatic, toxic, and infectious lesions; polycystic ovarian
disease.
?
Pychological factors: anxiety, stress, emotional trauma; psychotrophic
drugs, drug addiction, exogenous steroid administration.
?
Intermediate causes: chronic illness, metabolic or endocrine diseases,
nutritional disturbances.
?
Peripheral causes: functional ovarian cyst, functional tumors, premature
ovarian failure.
?
Physiologic: perimenarcheal and perimenopausal.

Perimenarcheal dysfunctional
uterine bleeding (DUB)
?
Adolescent DUB is primarily due to delayed, asynchronous or abnormal
hypothalamic maturation and inadequate positive feedback.
?
Usually associated with oligomenorrhoea, polymenorrhea or some
irregularity of menstruation due to delayed or failed ovulation with a failed
luteal phase support.
?
Uterine bleeding is occasionally severe and prolonged leading to severe
anaemia especially in truely anovulatory cycles.
?
In cases where this persists the existence of PCO must be excluded and the
teenager treated with cyclic hormones or oral contraceptives.

Menstrual disorders
Reproductive Age
? In the reproductive age, psychologic causes of
menstrual disorers involve marital and sex life, a
detailed history might reveal significant events that
precedes anovulatory episodes.
? History of broken relationships, alcoholism or drug
addiction and school or social pressures.
? Polycystic ovarian syndrome common finding:
obesity, hirsutism, anovulatory cycles (failure of
follicular development), endometrial hyperplasia.

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