Dysmenorrhoea is defined as the presence of severe pain during menstruation that interferes with the day to day activities of the patient.

Dysmenorrhoea can be categorized into two, primary dysmenorrhoea (spasmodic dysmenorrhoea) and secondary dysmenorrhoea (also known as congestive dysmenorrhoea).

Primary Dysmenorrhoea (spasmodic dysmenorrhoea)

This is the commonest type of dysmenorrhoea ,which mainly affects teenage adolescents. The pain usually starts a few hours before menstruation and persists for 1-2 days. The pain is spasmodic or colicky in nature (gripping on and off pain).

Primary dysmenorrhoea typically starts 1-2 years after menarche (the first menstrual period in her life), that is once the menstrual cycles become ovulatory.

This condition generally improves after pregnancy.

Although the exact cause is not known, it is thought that increased production of PGF-2 alpha during ovulation may be the cause.

Secondary Dysmenorrhoea (Congestive Dysmenorrhoea)

This is much less common than primary dysmenorrhoea.

In secondary dysmenorrhoea the patients ase generally of an older age group.

The complain usually starts after several years of normal painless menstruation.

Unlike in primary dysmenorrhoea, here the pain precedes the menstrual bleeding by several days, and tends to subside once the bleeding starts.

The cause is mostly due to underlying pelvic pathology.

There will also be symptoms related to the underlying cause (eg dyspareunia- pain during coitus).

Some of the common causes of secondary dysmenorrhoea include adenomyosis, endometriosis, uterine fibroids, pelvic inflammatory disease (PID) and the presence of a foreign body in the uterus (such as IUCD).

Amenorrhoea

Amenorrhoea is defined as absense of menstruation.

Amenorrhoea can be either physiological or pathological amenorrhoea.

A) Physiological amenorrhoea

This occurs in normal individuals, it is a normal physiological process.

causes of physiological amenorrhoea are:

-Pre menarchial period

-Post menopausal period

-Pregnancy

-Lactation

-Following hysterectomy

B)Pathological Amenorrhoea:

Pathological amenorrhoea can be defined as the failure to mensurate for a period of at least 6 months, during the normal reproductive years of life, and not due to any physiological causes (given above).

Pathological Amenorrhoea can be classified into Primary Amenorrhoea and Secondary Amenorrhoea

Primary Amenorrhoea:

primary amenorrhoea is defined as failure to start menstruation at the normal age of menarche.

This is clinically significant at 16 years of age in a patient with normal secondary sexual characteristics and at 14 years in a patient who has not developed secondary sexual characteristics.

What are the causes of primary amenorrhoea?

i) Turner syndrome/Turner mosaics

ii) Gross congenital anomalies (mullerian agenesis/ blind ended vagina)

iii)Androgen insensitivity syndrome (also known as testicular feminization syndrome).

iv) Panhypopituitarism/ hypopitiuatarism

v) Severe malnutrition/ anorexia nervosa

vi) Late onset congenital adrenal hyperplasia

vii) Polycystic ovary disease.

Secondary Amenorrhoea:

Secondary amenorrhoea is defined as absense of menstruation for a period of at least 6 months in a woman who has had normal menstruation prior to that, and who is still pre-menopausal.

What are the causes of secondary amenorrhoea?

i) Cerebral Cortex

-Anorexia nervosa

-Severe physical/Psychological stress

-Starvation/malnutrition

ii) Hypothalamus

-Intracranial tumours/ craniopharyngioma

iii)Pituitary

-Sheehans syndrome (or symonds disease-post partum pituitary necrosis)

-prolactinomas

iv) Ovary

-polycystic ovary disease

-congenital adrenal hyperplasia

-androgen secreting ovarian tumours

-premature ovarian failure (eg due to cytotoxic therapy)

v)Uterus

-Asherman syndrome

-endometrial TB

vi) General

-Chronic renal failure

-Chronic liver disease

-Adrenal failure

-Severe diabetes mellitus

-hyper/hypothyroidism

-iatrogenic (Phenothiazine drugs)

References:

Introduction to Clinical Gynaecology and Obstetrics for Undergraduates. Compiled by Dr WDN De Alwis, Dr  .R Gnansekeram, Dr .N.Gunawansa. Edited by Dr C. Randeniya MBBS, MS, FRCOG. Senior Lecturer, Dept. of Obstetrics and Gynaecology, Faculty of Medicine, Colombo. Honorary Consultant, De Soysa Hospital for Women and the National Hospital of Sri Lanka.

-Age of menarche (Her age when she first had her first menses)

-The frequency of the cycle.

-For how long does she have the bleeding in each cycle. (how many days?)

-estimated quantity of bleeding (No. of pads used)

-Is there associated pain during the menses?How severe is it?

-Is there passage of any clots/ altered blood

-When was the last date of menstruation-that is the period of amenorrhoea (POA).

2) Identification of the current irregularity in relation to that of the individual patient’s normal pattern.

The following should be compared with her previous normal periods

-Is the cycle lengthened or shortened? (cycle frequency)

-Is the quantity of bleeding increased, decreased or normal?

-Characteristics of the menstrual blood (Is it fresh blood,clots or altered blood?).

-Is there pain during her periods. What is the nature of the pain-is i colicky. What is its timing in relation to the cycle.

3) The history of the current menstrual irregularity should be taken:

-How long ago did the problem start (that is the onset of the problem-The last normal menstrual period)

-Are the symptoms getting worse, better or the same (The progression of the symptoms).

-How does she feel now (current status)

-Has she received any treatment, since the onset of the symptoms/present problem.

4) Ask a few questions to find the possible aetiological (Cause) factor:

-Depending on the pattern of menstrual irregularity, the probable cause should be identified, features that support or contradict your tentative diagnosis should also be noted

-It is important to ask for a past history of contraceptive usage.Hormonal contraceptives usage eg DMPA, OCP should also be noted.

-Pregnancy, lactation and use of contraceptives should be excluded

5)Ask questions to determine if there are any complications in her present problem/illness

-Look for clinical features of anaemia ,such as pallor etc.This is important in menorrhagia.

-Are there any associated problems such as subfertility.

-How does the present illness affect her general physical and social well being?

-Are there any associated disabilities? Can she perform the activities of daily living? (ADL) such as bathing, brushing her teeth etc.

-Look for any more complications related to the aetiological factor.

References:

Introduction to Clinical Gynaecology and Obstetrics for Undergraduates. Compiled by Dr WDN De Alwis, Dr  .R Gnansekeram, Dr .N.Gunawansa. Edited by Dr C. Randeniya MBBS, MS, FRCOG. Senior Lecturer, Dept. of Obstetrics and Gynaecology, Faculty of Medicine, Colombo. Honorary Consultant, De Soysa Hospital for Women and the National Hospital of Sri Lanka.

1)Menorrhagia

What is the definition of Menorrhagia?

Menorrhagia is defined as abnormally excessive bleeding (>80ml) during menstruation. The menstrual cycle is regular, but the bleeding may be excessive, either in quantity or duration or both.

Since the frequency of the menstrual cycle remains unchanges ,the function of the hypothalmo-pitiutary-ovarian (H-P-O) axis is normal.

What are the common causes of Menorrhagia?

a)Gynaecological Causes:

i) Uterine fibroids (Submucosal or intramural)- The net surface area of the endometrium is increased by sub mucosal fibroids. Intramural fibroids prevent normal uterine contractions.

ii)Adenomyosis- This reduces the contractility of the uterus, while increasing the surface area of the endometrium and increases the vascularity of the uterus.

iii)Chronic Pelvic Inflammatory Disease (PID).

iv)Pelvic endometriosis.

v)Intrauterine Contraceptive Device (IUCD) in utero (Inside the uterus).

vi)Intrauterine structural abnormalities eg bicornuate uterus

b)Medical causes:

i) Hypothyroidism

ii)Bleeding disorders eg Idiopathic thrombocytopenic purpura (ITP), von willibrand factor deficiency (VWF- deficiency).

c) Dysfunctional :

Here the cause is not really known. But it is thought to be due to elevated endometrial PGE-2 levels and increased fibrinolytic activity.

2)Oligomenorrhoea:

What is the definition of oligomenorrhoea?

Oligomenorrhoea is defined as abnormally prolonged menstruation cycles, where the bleeding occurs with a cycle frequency of more than 35 days, or where the amount of bleeding is reduced either in quantity (<20ml) or duration (<2 days).

It must be noted that in oligomenorrhoea the function of the hypothalmo-pitiutary-ovarian (H-P-O) axis is disrupted (not normal).

What are the common causes of oligomenorrhoea?

i) It is commonly due to Polycystic ovarian disease (PCOD).

ii) Asherman syndrome- due to repeated endometrial curettage.

iii) Endometrial tuberculosis (This is now very rare.

3) Epimenorrhoea:

What is the definition of epimenorrhoea?

Epimenorrhoea is defined as menstrual bleeding which occurs with an abnormally short cycle frequency (<21 days).

It must be noted that in epimenorrhoea the function of the hypothalmo-pitiutary-ovarian (H-P-O) axis is disrupted (not normal).

In epimenorrhoea ,the quantity and duration of bleeding is normal.

What are the common causes of epimenorrhoea?

i) Chronic Pelvic Inflammatory Disease (PID).

ii)Salpingo-oophritis (infection of the uterine tubes and ovaries).

4) Metrorrhagia:

What is the definition of metrorrhagia?

Meteorrhagia is defined as bleeding which takes place between normal menstrual cycles (It is also known as intermenstrual bleeding).

Here the function of the hypothalmo-pitiutary-ovarian (H-P-O) axis is normal.

The menstrual cycles occur normally ,but are interrupted by bouts of bleeding in between.

What are the common causes of metrorrhagia?

This is due to surface lesions of the genital tract

i) Cervical erosion

ii)Endometrial polyps

iii)Carcinoma of the cervix

iv)Cervical polyps.

To be Continued in PART 2

References:

Introduction to Clinical Gynaecology and Obstetrics for Undergraduates. Compiled by Dr WDN De Alwis, Dr  .R Gnansekeram, Dr .N.Gunawansa. Edited by Dr C. Randeniya MBBS, MS, FRCOG. Senior Lecturer, Dept. of Obstetrics and Gynaecology, Faculty of Medicine, Colombo. Honorary Consultant, De Soysa Hospital for Women and the National Hospital of Sri Lanka.