Menstrual disorders in adolescent girls!

Phase of transition from childhood to adulthood

Constitute about one fifth of India’s population

Adolescents constitute a diversified group- School vs college going, married vs unmarried, educated vs uneducated, rural vs urban, different cast/ religion/ localities.

Broadly important problems of adolescents are :–

1. Body image issues – Rapid change in the bodies frequently make them compare with one another and may result in some psychological problems.
2. Nutrition – due to gender discrimination girls are affected more by malnutrition and anemia which later have adverse affects on pregnancy and to newborn.
3. Menstrual disorders :-

• AUB (Abnormal uterine bleeding)- refers to bleeding that is excessive or occurs outside the normal cyclic pattern. The most common cause of AUB in the first 19 months after menarche is anovulatory cycles due to immaturity of the hypothalamic- pituitary- ovarian axis. Some other common causes may be related to stress, eating disorders, bleeding disorders & endocrine disorders like hypothyroidisms/ PCOS.

 DEFINITION :- Any change in the :

        Frequency of menstruation (24 – 35)

         Duration of flow (4 – 7 days) or

        Amount of blood loss (5- 80 ml)

 Traditional terms describing abnormalities of menstrual bleeding:-

           Amenorrhea – absent menses

           Oligomenorrhea – infrequent menses, occurring at intervals > 35 days

           Polymenorrhea – frequent menses, occurring at intervals < 24 days

           Metrorrhagia – menses occurring at irregular intervals

Menorrhagia or hypermenorrhea – abnormally long or heavy menses, lasting  > 7 days       or involving blood loss > 80 ml

Causes :- ovulatory dysfunction ( hypothalamic- pituitary- ovarian axis )

             – pregnancy related complications

             – bleeding diathesis ( thrombocytopenia, von Willebrand disease or leukemia )

             – infections

             – stress (psychogenic, exercise induced )

Management : oral hematinics to correct anemia, hemostatics (tranexamic acid), weight reduction if obese, hormones 9 cyclic progestrones, OCPs), treating underlying cause

• Amenorrhoea
• Primary amenorrhoea – the absence of menstruation by age 16 yrs in the presence of secondary sexual characterstics or by age of 14 yrs  in the absence of secondary sexual characterstics. Causes : congenital abnormalties in the development of ovaries/ genital tract or external genitalia….. Disturbance of the normal endocrinological events of puberty (40%).
• Secondary amenorrhoea- the absence of 3 or more subsequent menstrual periods with formerly regular cycles. Cause : pituitary gland tumor,, an overactive thyroid gland, PCOS, obesity, stress, heavy exercise, low body fat.
• Management – treatment of underlying cause
• DYSMENORRHEA (painful periods/ menstrual cramps) one of the most common gynaecological SYMPTOM that affect the quality of life of women. the term dysmenorrhea is derived from greek words dys – painful/ abnormal; meno – month and rrhea – to flow.

PRIMARY DYSMENORRHEA

Dysmenorrhea is primary when it occurs in the absence of co-existent pelvic pathology. It is due to excessive levels of prostaglandins (hormone ) which stimulates uterine contractions and vasoconstriction (the constriction/narrowing of the blood vessels) which potentiate myometrial (the middle layer of the uterus) ischemia (inadequate blood supply) causing pain.

Age at onset : 16–25 yrs

Onset of pain (spasmodic) is just prior to menstruation.

usually self-limited.

SECONDARY DYSMENORRHEA

Dysmenorrhea is secondary when there is an identifiable anatomic or macroscopic pelvic pathological condition. There may be associated vaginal discharge, dysperiunia (painful sexual intercourse), menorrhagia (heavy bleeding at menstruation).

Age at onset : 30- 45 yrs

Onset of pain : Pain (congestive) increases through the luteal phase (before period starts) peaking at onset of menstruation.

Secondary dysmenorrhea may arise from a number of underlying pathological conditions.

COMMON CAUSES

1. Endometriosis
2. Pelvic Inflammatory Disease ( Infections)
3. Adenomyosis
4. Intrauterine polyps
5. Submucosal fibroids
6. IUCDs

LESS COMMON

– Congenital uterine abnormalities

– Cervical stenosis

– Asherman syndrom

– Chronic ectopic pregnancy

– Pelvic congestion syndrome

– Ovarian cysts or neoplasms

RISK FACTORS FOR DYSMENORRHEA

Young age, early menarche, heavy menstrual flow, nulliparity (state in which a woman has never carried a pregnancy), smoking, depression, anxiety, stress.

MANAGEMENT

Treatment of dysmenorrhea is aimed at providing symptomatic relief as well as inhibiting the underlying processes that causes symptoms.

Primary dysmenorrhea respond to

1. NSAIDs (nonsteroidal anti-inflammatory drugs, blocking production of prostaglandins) that provide analgesic (pain-killing) and anti-inflammatory effects eg: aspirin, ibuprofen and naproxen. Should be offered as first line treatment for pain relief.
2. COCs (combined oral contraceptives) are commonly used as a second line therapy when NSAIDs are ineffective, poorly tolerated or contraindicated. COCs inhibit ovulation and endometrial tissue growth, thereby decreasing prostaglandin release. Contraception is the additional benefit of COCs.

Treatment of Secondary dysmenorrhea must address the underlying disease ( cyst removal/ removal of submucosal fibroids/polyps etc ). Secondary dysmenorrhea may be resistant to NSAIDs and COCs.

PCOS is the most common endocrine (hormones) syndrome affecting women of reproductive age. It is more prevalent in obese women (28%) than those who are lean.

The effects of PCOS manifest via deranged hormonal profiles, excess of circulating androgen (free testosterone) , increase LH, decrease FSH, Insulin resistance, decrease SHBG (sex hormone binding globulin is a glycoprotien that binds to the two sex hormones:androgen and estrogen).Obesity induced insulin resistance causes an exacerbation of all the symptoms of PCOS.

Lifestyle modification, including a minimum of 30 min of moderately intense exercise at least 3 days per week and dietary interventions is the first line treatment. A weight loss of 5–10% has been shown to decrease testosterone concentrations, increase SHBG, normalize menses and improve fertility in women with PCOS. Prevention of excess weight gain should be emphasized in all women with PCOS with both normal & increased body weight.

• Endometriosis : endometriosis defined as presence of estrogen dependent endometrial like tissue found outside uterus resulting in sustained inflammatory reaction. Adolescent girls suffering from chronic pelvic pain 70-80% are reported to have endometriosis. The diagnosis is often delayed in the adolescent girls for a period of more than 6-8 yrs if high index of suspicion is not there. To be suspected in adolescents when they have severe dysmenorrhea interfering with daily activities not responding to NSAIDs and OCPs.

               Management – continous use of OCPs, progestin, GnRH agonists are used only for girls  beyond 16 yrs, LNG- IUS  can be used in sexually active adolescents.

• PREMENSTRUAL SYNDROME – A condition which manifests with distressing physical, behavioral and psychological symptoms in the absence of organic or underlying psychiatric disease, which recurs regularly during the luteal phase of each menstrual cycle and disappears or significantly regresses by the end of each menstruation.

          PMDD – Premenstrual dysphoric disorder, a severe subtype of PMS.

            Symptoms of PMS and PMDD :

Grading of severity

• Mild – symptoms do not interfere with personal/ social and professional life.
• Moderate – symptoms interfere with personal/ social and professional life, however the individual is still able to function and interact.
• Severe – individual is unable to interact personally/ socially/ professionally – withdraws from social and professional activities

Management – dietary calcium and vitamin supplements, antidepressants, oral contraceptives, GnRH.