Menstrual Disorder PDF

 **Menstrual disorder** **Under supervision** - **Dr:-Asmaa Ibrahim** - **Dr:- Hala Haed** - **Dr:-Seham Elgaml** - **Dr:- Salwa Rezk** **Prepare word:-** - **Elham emad Mohamed** - **Amal Ibrahim Mohamed** - **Amany Maher Ahmed** - **Alaa Mohamed Har...

 **Menstrual disorder** **Under supervision** - **Dr:-Asmaa Ibrahim** - **Dr:- Hala Haed** - **Dr:-Seham Elgaml** - **Dr:- Salwa Rezk** **Prepare word:-** - **Elham emad Mohamed** - **Amal Ibrahim Mohamed** - **Amany Maher Ahmed** - **Alaa Mohamed Haridi** **Prepare power point:-** - **Alneroz said Ahmed** - **Alaa Mohamed masad** **Prepare presentation:-** - **Amal Khamis Ramadan** - **Alaa foad Abdelhamid** - **Alaa Mohamed Ibrahim** - **Alaa Mohamed mabrouk** - **Shaimaa Attieh Mohamed** - **Amany saber Ibrahim** **\*out line:-** **1- introduction** **2- Definition of menstruation, menstrual cycle & puberty** **3- characteristics of menstruation** **4- factor affecting menstruation** **5- physiological of menstruation** **6- Definition menstrual disorder** **7- type of menstrual disorder.** **\#Amenorrhea:** **"Definition** **"Classification** **"Causes** **" Investigation** **" Management** **\# Dysmenorrhoea.** **" definition** **" type** **Spasmodic dysmenorrhoea (primary )** **Congestive dysmenorrhoea (secondary)** **"causes** **"management** **"nursing role** **\#premenstrual syndrome (pms)** **"Definition** **"Causes** **"Management** **\#Heavy menstrual bleeding (menorrhagia)** **"Definition** **"Causes** **"Management** **\#other definition.** **" hypomenorrhea** **" oligomenorrhea** **"Polymenorrhea** **"Metrorrhagia** **"Memos taxis** **" Metropathia** **"Metropathia hemorrhagica** **"Dysfunction uterine bleeding** **\*Introduction:-** **The human female is monotonous.multiple pregnancy is a rare event in our species and lead to complication that can lead to maternal or fetal death in day before modern medicine.Regular monthly menstruation is the obvious marker that determine level of interaction between hypothalamus, pituitary,ovary and uterus are function so interruption at any point lead to disorder menses** **Menstrual disorders are problems that affect a woman's normal menstrual cycle. They include painful cramps during menstruation, abnormally heavy bleeding, or** **Menstruation occurs during the years between puberty and menopause. Menstruation, also called "menses" or a "period," is the monthly flow of blood from the uterus through the cervix and out through the vagina.** **\*Definition:-** **\*puberty:-** **Is a phase of life during which the sex organ & function reach maturity and marked by the development of secondary sex characteristics** **\*menstruation:-** **Is monthly shedding of a portion of endometrium (compact &spongy layers) it's recurs regular form puberty to menopause except during pregnancy** **\*menstrual cycle:-** **Begins from the first day of one period to the first day of the next one** **\*characteristics of normal menstruation:-** **1-Age of menarche (onest)** **Occurs between (10-16) years with average of 13 years** **2-Interval of menstruation (cycle length)** **It's ranges between (21-35)days with average of 28years.under control of the hypothalamic \_pituitary \_ovarain axis** **3-Rhythm of menstruation** **Regularity of menstruation (regularly or irregular)** **4-Duration of menstruation** **Ranges between (3-7) days with average of 5 days** **5-Amount of blood loss** **Ranges between (30-80) mL with average of 50 mL presence of enzyme (fibrinolysin) prevent the blood from clotting** **\*Factor affecting the normal of menstruation** **A- Essential factor.** 1. **Intact outflow tract** 2. **Intact uterine organ with healthy endometrium responsive to ovarian hormone** 3. **Normal ovarian function depends upon (GnRH) releasing from pituitary gland** 4. **Normal pituitary gland function & hypothalamus function that greatly affects by the cerebral cortex** **B- Auxiliary factor** 1. **General & medical condition** 2. **Socioeconomic condition** 3. **Nervous status** 4. **Bodyweight changes** 5. **Normal thyroid gland function** 6. **Normal adrenal glad function** **\*Physiology of menstuation:-** **\*Definition of menstrual disorder:** Any conditions of irregularities that are related to the woman menstrual cycle **Type of menstrual disorder:-** **Amenorrhea:** **Definition :** **It means the absence or stopping of menstruation during the reproductive years.** **Amenorrhea is considered a symptom and not a disease.** **Classification :-** ** According to the onset:** - **Primary a menorrhea:** - **Absence of menstruation until the age of 16 years in the presence of secondary sexual characteristics.** - **Or Absence of menstruation until the age of 14 years in the absence of secondary sexual characteristics.** - **Secondary amenorrhea:** - **Stopping of menses for more than three consecutive cycle intervals or 3-6 months in women who were previously menstruating.** **\*According to the causes:-** A. **Physiological amenorrhea: Amenorrhea that is normal to occur :** - **Before puberty :** **Lower gonadotrophins with low estrogen and progesterone** **Pregnancy:-** **Continuous estrogen and progesterone production without withdrawal.** **High prolactin production resulting in ovarian suppression.** **Menopause:-** **Exhaustion of the ovarian follicles with low estrogen and progesterone.** **B.pathological amenorrhoea:-** 1. **False amenorrhea (crypto menorrhea):** **Definition:-** **Also known as hematocolpos, is a condition where menstruation occurs but is not visible due to an obstruction of the outflow tract on the level of vagina. Specifically, the endometrium is shed, but a congenital obstruction such as a vaginal septum or on part of the hymen retains the menstrual flow. The blood retained inside the vagina results in hematocolpos and may be inside the uterus resulting in hematometria. A patient with cryptomenorrhea will appear to have amenorrhea but will experience cyclic menstrual pain. The condition is surgically correctable** **Causes:** 1. **Cervical atresia.** 2. **Vaginal causes :** **⁠a) Vaginal aplasia** **b) Vaginal atresia** **c) Transverse vaginal septum.** 3. **Imperforate hymen (considered the most important cause)** **Clinical picture :** **Symptoms** 1. **Primary amenorrhea.** 2. **Recurrent cyclic colicky lower abdominal pain.** 3. **Abdominal mass (mistaken as pregnancy).** 4. **Pressure symptoms particularly on the urethra resulting in acute urine retention.** **Sign:-** - **General examination: reveals well-developed secondary sexual characters.** - **Abdominal examination: reveals central cystic abdominal mass is dull on percussion** - **Vaginal examination:** a. **In the presence of imperforate hymen.** - **Bulging bluish-colored distended complete hymen** - ** The bulging increases with cough (positive impulse on cough).** **⁠b) In the presence of transverse vaginal septum.** - **The hymen is normal with the site of the obstruction above the level of the hymen.** - **Usually does not bulge with straining.** - **Cross fluctuation is detected on per rectal (PR) examination.** **c) In the presence of cervical atresia (only hematometria is.present): the vagina and hymen may be normal and the uterine sound does not pass the cervical canal.** **.Investigations :** ** Ultrasonography: it can show hematocolpos and hematometria is present.** ** Intravenous pyelography: aiming to detect associated urinary abnormalities e.g. pelvic kidney.** **\*.Management :-** ** Imperforated hymen: partially hymenectomy, Patient was planned for resection of hymen and a cruciate incision was given over the hymen and around 700 ml of collected blood was drained. Eversion and suturing of edges of incision was done to maintain patency of outflow tract. Follow up visit at 3 months.** ** Transverse vaginal septum is treated by incision through removing of septum.** ** Vaginal aplasia through plastic surgery** ** Vaginal atresia through widening and applying stent** 2. **True amenorrhea:** **I: uterine causes of amenorrhea.** **II: ovarian causes of amenorrhea.** **III: pituitary causes of amenorrhea.** **IV: hypothalamic causes of amenorrhea.** **\*Uterine causes of amenorrhea. :-** 1. **Congenital :** a. **Aplasia (mullerian agenesis).** b. **Sever degree of uterine hypoplasia.** 2. **Traumatic: Surgical removal of the uterus.** 3. **Inflammatory: Tuberculous endometritis** 4. **Asherman's syndrome: Intra uterine adhesions (secondary)** **Ovarian causes of amenorrhea:** a. **Ovarian hypo function (Gonadal failure** 1. **Gonadal dysgenesis e.g. Turner's syndrome.** 2. **Pre mature ovarian failure owing to:** ** Surgical removal of both ovaries.** ** Mumps or tuberculous infection of both ovaries.** ** Post irradiation or after chemotherapy.** ** In association with autoimmune diseases.** b. **Ovarian hyper function (Hyper hormonal amenorrhea) as in:** 1. **Ovarian tumours.** 2. **Polycystic ovarian syndrome (PCOS) in which an ovulation is associated hyperandrogenism.** 3. **Persistent corpus luteum (Halban's syndrome).** **Pituitary causes of amenorrhea:** 1. **Pituitary adenomas:** **The commonest form of pituitary disease seen in association with amenorrhea is pituitary adenoma. The commonest of these the prolactinoma, which is non cancerous tumour of pituitary gland causing increase in prolactin and decrease in estrogen and progesterone.. The prolactinoma may be microprolactinoma (\1cm) which press on optic nerve causing manifestations of increase intracranial pressure, and elevated prolactin level.** 2. **Pituitary cachexia (simmond's disease):** **It means the destruction of the pituitary gland by a non-obstetric cause e.g. tuberculosis,** 3. **Sheehan's syndrome:** **It means destruction of pituitary gland by obstetric causes as severe antepartum or postpartum hemorrhage.** I. **Hypothalamic causes of amenorrhea:** A. **Organic causes:** 1. **Destructive tumor as craniopharyngioma.** 2. **Cerebrovascular accidents.** B. **Functional causes:** 1. **Anorexia nervosa: It means a psychiatric disorder associated with loss of appetite and disturbed body image. It is prevalent in middle-aged females, models, and in ballet dancers. The amenorrhea is here due to stress which suppresses the GnRH release from the hypothalamus with subsequent ovarian suppression and amenorrhea with genital atrophy. The treatment of anorexia nervosa is by psychotherapy and induction of ovulation by human menopausal gonadotropin (HMG) if pregnancy is wanted.** 2. **Bulimia nervosa: It means psychiatric illness with disturbed female body image. The female has a good appetite but she induces vomiting or use purgatives to avoid obesity. The treatment is similar to anorexia nervosa.** 3. **Athletic amenorrhea: In athletes, owing to the stress from strenuous exercise, the GnRH release from the hypothalamus is inhibited, with increase in prolactin level with amenorrhea as the ultimate result.** 4. **Psychological upset** C. **Drugs that act on hypothalamus.** 1. **Injectable contraceptives** 2. **GnRH** 3. **Electroconvulsant therapy** **Therapeutic management** **Therapeutic intervention depends on the cause of the amenorrhea. The treatment of primary amenorrhea involves the correction of any underlying disorders and estrogen replacement therapy to stimulate the development of secondary sexual characteristics. If a pituitary tumor is the cause it might be treated with drug therapy, surgical resection, or radiation therapy. Surgery might be needed to correct any structural abnormalities of the genital tract therapeutic interventions for secondary amenorrhea may include:** ** Cyclic progesterone when the cause is an ovulation, or oral contraceptives.** ** Bromocriptine to treat Hyperprolactinemia.** ** Nutritional counseling to address anorexia, bulimia, or obesity.** ** Gonadotrophin- releasing hormone (GnRH), when the cause is hypothalamus failure.** ** ⁠ Thyroid hormone replacement. When the cause is hypothyroidism.** **Nursing assessment** a. **Nursing assessment:** - **Health History:** - **Women menstrual history** - **⁠- Past illness** - **Hospitalization and surgeries.** - **Obstetric history** - **Medications.** - **Recent or past life style changes -- History of present illness** - **Physical examination:** 1. **Should begin with overall assessment of the women's nutritional status and general health.** 2. **Assistive and gentle approach to pelvic examination is critical in young women.** 3. **Height and weight should be taken, along with vital signs.** 4. **Hypothermia, bradycardia, hypotension, and reduce subcutaneous fat may be observed in women with anorexia nervosa.** 5. **Facial hair and acne might be evidence of androgen excess secondary to tumor.** 6. **The presence or absence of axillaries and pubic hair may indicate adrenal and ovarian hypo secretion or delayed puberty.** - **Laboratory investigatio** ** Karyotype (might be positive for turner syndrome).** ** Ultra sound to detect ovarian cysts.** ** Pregnancy test to rule out pregnancy.** ** Thyroid function studies to determine thyroid disorder** ** Prolactin level (an elevated level might indicate a pituitary tumor).** ** FSH level (an elevated level may indicate ovarian failure).** ** LH level (an elevated level may indicate Gonadal dysfunction).** ** Laparoscopy to detect poly cystic ovary syndrome.** ** CT scan of head if a pituitary tumor is suspected.** **Nursing Management :** c. **Proper balanced diet.** d. **Correction of body weight.** e. **A moderate exercise program may restore normal menstruation.** f. **Finding ways to deal with stress and conflicts may help.** g. **Maintaining a healthy lifestyle** h. **The follow-up is performed to monitor ovarian hormonal replacement.** **Dysmenorrhea** **Definition:** **Dysmenorrhea is painful menstruation that incapacitate the women make her unable to perform her work, keep her in bed or force her to ask for medical advice.** **Types** **A.Spasmodic Dysmenorrhea (Primary):** **Synonyms: primary, uterine, essential, intrinsic, or colicky dysmenorrhea** **Menstrual pain without organic pelvic pathology it is characterized by:** 1. **Usually started few years (2-3) after menarche, as early menstrual cycle are anovular and painless.** 2. **It is prevalent in virgins and nullipara women between 15-25 years.** 3. **Pregnancy and child birth usually cure spasmodic dysmenorrhea.** 4. **Starts with the onset of menstrual flow for 1 or 2 days.** 5. **The pain is colicky in nature recurs e very 5-30 min for a duration is 0.5-1 min the pain is felt suprapubic region may radiate to back and anterior aspect of the thighs.** 6. **Pain is associated with nausea, vomiting, diarrhea & fainting or bladder irritation.** **Causes of spasmodic dysmenorrhe** 1. **Increased prostaglandins in the menstrual blood:** **The increase both prostaglandin F2a and prostaglandin E in the menstrual blood by progesterone hormone (only in ovular cycles) prostaglandin F2a is potent uterotonic agent causing uterine angina while prostaglandin E increase sensitivity of nerve endings.** 2. **Increase endothelin in the menstrual flow:** **Endothelin are potent uterotonic and vasoconstrictors substances causing uterine ischemia.** 3. **Psychological factors:** **Wrong belief that the menstruation must be painful may play a role.** **4. Variants of normal anatomy as:** **a. Congenital pin hole os.** **b. Malposition (acute AVF or congenital RVF)** **c. Uterine hypoplasia, bicornute uterus, and septate uterus.** **5. Deficient polarity of the uterus:** **Deficient polarity may result from abnormal arrangement of uterine muscular layers causing failure of cervical dilatation during contraction of uterine body.** **Management of spasmodic dysmenorrhoea** **a) Preventive measures:** **1. Education of physiology and hygiene of menses** **2. Psychological support.** **3. Correction of over or under weight** **4. Elimination of stress** **5. Exercise** **b) General measures:** **1. Bed rest during the menstruation.** **2. Hot bottle application on the lower abdomen.** **c) Medical treatment:** **1. Analgesics and antispasmodics** **2. Prostaglandins synthetase inhibitors as (NSAID) as aspirin, ibuprofen \....** **3. Beta adrenergic receptor stimulants** **4. Calcium channel blockers** **d) Hormonal treatment** **1. COCs pills that inhibit ovulation and corpus luteum formation.** **2. Estrogen is useful in cases of hypoplasia** **e) Surgical trcatment** **Indicated in sever spasmodie dysmenorhea or when medical treatment fails** **B. Congestive dysmenorrhea (Secondary):** 1. **Appears at late time to the age of menarche, more prevalent betwoen 30-40 years.** 2. **Pain starts several days before menstruation, usually 2-3 days before menses and is relieved by the onset of the flow.** 3. **Constant dull ache or heaviness pain felt in the lower abdomen.** 4. **Pre menstrual excessive vagina discharge, deep dyspareunia menorrhagia is usually present due to pelvic congestion.** 5. **Associated with nausea & vomiting, headache & general malaise.** - **Cause of congestive dysmenorrhea:** b. **Inflammatory,** **Chronic cervicitis** **Chronic PID** **Parametritis.** c. **Uterine displacement.** d. **Varicose vein in broad ligaments** e. **Neoplastic** **Ovarian tumors** **Endometriosis (uterine or extrauterine).** **Mauagement of congestive dysmenorrhea:** 1. **Treatment of the underlying organic cause.** 2. **Measures to decrease pelvic congestion.** i. **Avoid constipation.** ii. **Decongestant vaginal suppositories.** **iii. Hot vaginal douches.** 3. **Analgesics and anti-inflammatory drugs are also helpful.** **To diagnose spasmodic dysmenorrhea** **1. Medical History: Review the menstrual history and symptoms.** **2. Physical Examination: Conduct a pelvic exam to rule out other issues.** **3. Symptom Assessment: Analyze the nature and timing of the cramps.** **4. Imaging Tests: Use ultrasound to check for structural problems if necessary.** **5. Response to Treatment: Assess how well the pain responds to medications like NSAIDs.** **6. Monitoring: Keep a menstrual diary to track patterns.** **Congestive dysmenorrhea is diagnostic** **1. Medical History: Collect information on menstrual cycles and symptoms.** **2. Symptom Assessment: Evaluate the nature of pain and any associated symptoms like bloating.** **3. Physical Examination: Conduct a pelvic exam to check for abnormalities.** **4. Hormonal Testing: Test hormone levels if imbalances are suspected.** **5. Imaging: Use ultrasound or MRI to identify pelvic issues like fibroids or endometriosis.** **6. Treatment Response: Monitor how symptoms respond to medications.** **The nursing role in managing dysmenorrhea includes:** **1. Assessment: Evaluating the patient's symptoms, medical history, and severity of pain.** **2. Education: Providing information about dysmenorrhea, its causes, and treatment options.** **3. Pain Management: Administering medications, such as NSAIDs, and recommending non-pharmacological methods (e.g., heat therapy).** **4. Supportive Care: Offering emotional support and encouragement, especially for those with severe symptoms.** **5. Monitoring: Observing the patient's response to treatment and adjusting care as needed.** **6. Referral: Guiding patients to specialists if secondary dysmenorrhea is suspected.** **\*Premenstrual syndrome (PMS):\*** **\*Definition :\* It is the occurrence of cyclical somatic and psychological symptoms that occur in luteal phase of menstrual cycle and resolve by the onset of menstruation about one to two weeks before menstruation and can cause variety of physical and emotional symptoms that can interfere with daily life.** **\*Causes of PMS:\*** 1. **Progesterone may lead to decrease of GABA which inhibitor to brain** **2. Low serotonin levels in the brain.** **3. Lifestyle factors : stress, lack of exercise and poir diet.** **4. Genetics: A family history of PMS may increase the likelihood.** **\*Clinical features:\*** **➤ Physical Symptoms:** **-Breas tension** **\_ headache** **\_bloatedness** **\_weight gain** **\_ edema** **\_ back and lower abdominal pain** **\_fatigue** **\_sleeping disorders** **\_craving for sweets.** **➤ \*Psychological Symptoms :\*** **-Irritability** **\_mood swings** **\_ depression** **\_concentration difficulties** **\_memory problems \_anxiety** **\_ aggressive behavior** **\_withdrawal** **\_crying** **\*➤ Diagnosis\*** **There is no specific test for PMS. Diagnosis is typically based on a review of symptoms and their timing in relation to the menstrual cycle. Keeping a symptom diary can be helpful for both the individual and healthcare provider.** **\*Management of PMS:\*** **\_Selective serotonin reuptake inhibitors** **\_Diuretics may be helpful in treatment of bloating and breast tenderness.** **\_Combined Oral contraceptive pills to inhibit ovulation.** **\_Use of non-steroidal anti inflammatory drugs (NSAIDs) as aspirin.** **\*Nursing role:\*** ** Prevention of primary dysmenorrhea through health education about physiology of menstruation, carrying normal activities, participating exercises, taking bath, relieving constipation, correcting underweight, overweight &anemia.** ** Complete history, examination & investigation.** ** Health teaching about how to reduce pain by using hot water bottle & waist exercise to divert attention.** ** Health teaching about hygienic care.** ** Salt free diet one week before menstruation in case of premenstrual tension.** ** Psychological support through reassurance & advice.** **\*Heavy menstrual bleeding (HMB; previously called menorrhagia).\*** **➤ \*Definition:\*** ** \*Clinical definition:\* Excessive menstrual blood loss that interferes with the woman's physical, emotional, social and quality of life, and which can occur alone or in combination with other symptoms.** ** \*Objective definition:\* This is blood loss of \>80 mL in an otherwise normal menstrual cycle. In practice, actual blood loss is rarely measured.** **➤ \*Epidemiology:\*** **One-third of women complain of heavy periods although most do not seek medical help.** **➤ \*Causes:\*** **\*A. General causes\*** 1. **Early hops and hi periodiss** **2 Blood diseases** **Acute infectiour fevers** **4 Congestive heart failure** 4. **Fatigue and chronic constipation** 5. **Hypertension and** **7 change to a hot climate** **\*B. Local causes\*** 1. **Fibroida tappiosionately 30% of women with HMB)** 2. **Polyps (approximately 10% of women)** 3. **Thickened Chyper plastic) endometrium** 4. **Chronic pelvic infection,** 5. **Ovarian tumours and** 6. **Interference with venous return Drum the uterus eg RVF, werine prolapsed** 7. **KIUD** **\*➤ Symptoms** ** Excessive Bleeding: Soaking through one or more sanitary pads or tampons every hour for several consecutive hours.** ** Prolonged Menstrual Periods: Menstrual bleeding lasting more than seven days.** ** Blood Clots: Passing large blood clots during menstruation.** ** Fatigue: Feeling tired or weak due to blood loss, which can lead to anemia.** ** Interference with Daily Activities: The need to change sanitary products frequently or the inability to participate in normal activities due to bleeding.** **\*➤ Diagnosis\*** ** Take a detailed medical history and menstrual history.** ** Perform a physical examination, including a pelvic exam.** ** Order blood tests to check for anemia or clotting disorders.** ** Use imaging tests like ultrasounds to look for fibroids or polyps.** ** Perform endometrial biopsy if necessary to evaluate the uterine lining.** **➤ \*Investigations\*** ** To assess the effect of blood loss and fitness, the patient's haemoglobin is checked.** ** To exclude systemic causes, coagulation and thyroid function are checked only if the history is suggestive of a problem.** ** To exclude local structural causes, a transvaginal ultrasound of the pelvis is performed.** **➤ \*Treatment\*** ** Treatment for HMB depends on the underlying cause, severity of symptoms, and individual preferences. Options may include:** **\*(1) pharmacological treatment of menorrhagia :\*** **➤ \*first line\*** ** Intrauterine system (IUS) The levonorgestrel-releasing intrauterine system \*(LNG- IUS)\* is an excellent alternative to surgery for women with \*HMB\* who also seek reliable long-acting reversible contraception. The added health benefits of reduced menstrual bleeding and less anaemia.** **➤ \*Second line\*** ** Antifibrinolytics reduce blood loss by up to 50% by inhibiting endometrial fibrinolysis.** ** Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit endometrial prostaglandin production, leading to a reduction in menstrual blood loss.** ** Combined oral contraceptive(COCs)** **➤ \*Third line\*** ** Progestogens (high-dose oral or intramuscular.** ** Gonadotrophin\_releasinghormon(GnRH) anaogues.** **\*➤ Surgical treatment of menorrhagia:\*** ** Hysteroscope for polyps.** ** Myomectomy for fibroid.** ** Hysterectomy for endometrium cancer.** **➤ \*Lifestyle Changes:\*** **   Maintaining a healthy diet and exercise routine.** **   Managing stress levels.** **➤ \*Risk Factors\*** ** Women who are approaching menopause (perimenopause) may also skip periods. Occasional episodes of heavy bleeding are also common as women approach menopause.** **➤ \*Other risk factors include:\*** ** Weight. Being either excessively overweight or underweight can increase the risk for dysmenorrhea (painful periods) and amenorrhea (absent periods).** ** Menstrual Cycles and Flow. Longer and heavier menstrual cycles are associated with painful cramps.** ** Pregnancy History. Women who have had a higher number of pregnancies are at increased risk for menorrhagia.** ** Women who have never given birth have a higher risk of dysmenorrhea, while women who first gave birth at a young age are at lower risk.** ** Smoking. Smoking can increase the risk for heavier periods.** ** Stress. Physical and emotional stress may block the release of luteinizing hormone, causing temporary amenorrhea.** ** Exercise. Intensive athletic training is linked with late menarche and amenorrhea or oligomenorrhea.** **➤ \*Complications\*** ** Anemia** ** Infertility** ** Osteoporosis** **➤ \*Other definitiones:\*** **\*1. Hypomenorrhea\*:** **This means a decrease in the amount of menstrual flow while the periods are regular in hythm. The deficiency is either in the amount of blood lost or in the duration which is less than two days. It is frequently a step towards the development of amenorrhea.** **\*2.Oligomenorrhea\*** **This means normal periods at longer intervals ie the menstrual cycle is prolonged "eligo" in Greek means few, so the patient gets a fewer number of cycles per year, or Infrequent menstruation (length of the cycle is more than 35 days).** **\*3. Poly menorrhea\*** **It means short menstrual cycles or too frequent menstruation at regular intervals of 2 weeks but less than 3 weeks, with more periods per year The bleeding may not be excessive** **\*4.Metrorrhagia\*** **Irregular or unusual bleeding (bleeding at times other than those when period is expected) Bleeding may range from slight spotting to hemorrhagic flow & from a single short period to bleeding that continues for days.** ** It is a common symptom of** **Uterine malignancy especially endometrial carcinoma.** **Cervical erosions & poly** **\*5. Menostaxis\*** **➤ Definition** **It means a regular period with normal flow but prolonged duration Irregular response of endometrium to ovarian hormones, which lead to irregular necrosis of the endometrium \[an area is menstruating & other area is in premenstrual period (irregular ripening)\]** **\*6.Metropathia hemorrhagica\*** **This condition most commonly occurs around the time of the menopause but may occur** **➤ Definition:** **Period of amenorrhea followed by prolonged heavy & irregular bleeding of such severity that it may occasionally be life threatening. The persistence of an un-ruptured graffian follicle, which exists in one-ovary & results in extended & excessive estrogen production that causes cystic ovaries or adenomatous endometrial hyperplasia.** **\*7.Dysfunctional uterine bleeding\*** **➤ Definition:** **This term describes the occurrence of abnormal uterine bleeding for which organic causes cannot be found. Abnormalities of the uterine bleeding most commonly occur at the extremes of menstrual life & particularly in the premenopausal years. These conditions are classified as ovular or an ovular.** **\*1\_Ovular dysfunctional uterine bleeding:\*** **\_ Defective corpus luteum formation** **\_ Defective degeneration of the corpus luteum.** **\*2\_Anovular dysfunctional uterine hemorrhage:\*** **Such as metropathia hemorrhagica.** **\*Metropathia:\* is a term used in medical contexts to refer to a disease or disorder of the uterus. It can encompass a variety of conditions affecting the uterine tissue, including abnormalities, infections, or other pathologies.** **\*hemorrhagica:\*** **Typically refers to conditions characterized by bleeding or hemorrhage. It is often used in medical terminology to describe diseases or syndromes that involve significant blood loss or bleeding tendencies. For example, "purpura hemorrhagica" refers to a condition where there are purple spots on the skin due to bleeding underneath, and "hemorrhagic fever" describes a group of illnesses that can cause severe bleeding.** **➤ \*Management:\*** ** High dose of progesterone.** ** Endometrial resection.** ** Hysterectomy.** ** Curettage.** **References** 1. **American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206-218. PMID: 20027071 [www.ncbi.nlm.nih.gov/pubmed/20027071](http://www.ncbi.nlm.nih.gov/pubmed/20027071).** 2. **Bofill Rodriguez M, Lethaby A, Grigore M, et al. Endometrial resection and ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;1:CD001501. PMID: 30667064 [www.ncbi.nlm.nih.gov/pubmed/30667064](http://www.ncbi.nlm.nih.gov/pubmed/30667064).** 3. **Bulun SE. Physiology and pathology of the female reproductive axis. In: Melmed S, Auchus RJ, Goldfine AB, Koenig RJ, Rosen CJ, eds. Williams Textbook of Endocrinology. 14^th^ ed. Philadelphia, PA: Elsevier; 2020:chap 17.** 4. **Davies J, Kadir RA. Heavy menstrual bleeding: An update on management. Thromb Res. 2017;151(Suppl 1):S70-S77. PMID: 28262240 [www.ncbi.nlm.nih.gov/pubmed/28262240](http://www.ncbi.nlm.nih.gov/pubmed/28262240).** 5. **Fergusson RJ, Bofill Rodriguez M, Lethaby A, Farquhar C. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019;8:CD000329. PMID: 31463964 [www.ncbi.nlm.nih.gov/pubmed/31463964](http://www.ncbi.nlm.nih.gov/pubmed/31463964).** 6. **Haamid F, Sass AE, Dietrich JE. Heavy Menstrual Bleeding in Adolescents. J Pediatr Adolesc Gynecol. 2017;30(3):335-340. PMID: 28108214 [www.ncbi.nlm.nih.gov/pubmed/28108214](http://www.ncbi.nlm.nih.gov/pubmed/28108214).** 7. **Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013;(1):CD000400. PMID: 23440779 [www.ncbi.nlm.nih.gov/pubmed/23440779](http://www.ncbi.nlm.nih.gov/pubmed/23440779).** 8. **Lethaby A, Hussain M, Rishworth JR, Rees MC. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2015;(4):CD002126. PMID: 25924648 www.ncbi.nlm.nih.gov/pubmed/25924648**