Women’s Health

Conservative General Measures:

If the bleeding due to menorrhagia is not heavy and consequent anemia is not serious or hemoglobin is normal, the patient should be observed for few months, as in many cases there is spontaneous cure (recovery from menorrhagia) and it should be awaited. If the patient’s menorrhagia is severe there is always some degree of anemia. In this juncture the complete hemogram test should be done instead of doing only hemoglobin estimation. As a conservative measure oral iron preparation should be given to the patient and response to the oral iron checked by serial blood count and hemoglobin estimation (generally at least twice a month, if possible every week). If patient is not responding to iron satisfactorily due to any cause (may be due to iron intolerance, failure to utilize the oral iron etc.), she should be given parenteral iron preparation till anemia is fully corrected and body iron stores become normal. The patient should be reassured and bed rest and sedatives given, which plays important role in conservative management of menorrhagia. If anemia is severe, blood transfusion may be required.

Role of NSAIDs in menorrhagia:

The NSAID (non steroidal anti inflammatory drug) used is mefenamic acid 500 mg three times a day with full stomach. This is given for 5-6 days during menstruation in menorrhagia cases of ovulatory cycles, menorrhagia associated with IUCD, and post sterilization menorrhagia. The common side effects of mefenamic acid are nausea, vomiting, headache, dyspepsia, hemolytic anemia etc.

Role of antifibrinolytic drugs:

The drug which was tried with varying result in menorrhagia is epsilon-amino-caproic acid at the dose of 1-3 grams four times a day for 6-7 days. The side effects that are encountered with epsilon-amino-caproic acid are nausea, vomiting, headache, intracranial thrombosis etc.

Menorrhagia is a presenting symptom in many endocrine diseases. In patients with hyperthyroidism, menorrhagia is a frequent symptom, especially in early stage of the disease. In advance stage of hyperthyroidism patients usually have amenorrhea (absence of menstruation). In hypothyroidism menorrhagia is generally seen in the advanced stage of the disease. Menorrhagia is a common symptom in myxedema (disease of hormonal disturbance), especially in women above 40 years of age. In acromegaly (due to excess production of growth hormone in adults) menorrhagia can be a symptom in early stage and in the late stage usually there is amenorrhea.

Iatrogenic causes of menorrhagia:

Menorrhagia may also develop due to use of estrogen for prolonged period for non gynecological condition (especially use of synthetic estrogen prescribed by dermatologists, for relief of symptoms which is not a gynecological problem). The use may be for long duration and at a dose that may be of high. Estrogen is also frequently prescribed by many doctors for menopausal symptoms, and this prescription (of estrogen) may itself cause menorrhagia. Both of the above instances can be regarded as iatrogenic (caused by doctor’s prescription or hospital acquired).

IUCD as a cause of menorrhagia:

IUCD (intrauterine contraceptive device, used as a method of contraception by women), can also cause menorrhagia as seen in recent times. In fairly large percentage of women using IUCD develop menorrhagia in first few periods after insertion of IUCD and in some women the device has to be withdrawn due to continuation of menorrhagia for long duration.

In approximately 15% of cases of tubectomy (sterilization operation in women in which part of Fallopian tube is removed and both ends are ligated to prevent re-canalization) also menorrhagia is seen although the cause is not clear.

Local pathology in the female pelvis is a common cause of menorrhagia, along with other causes of menorrhagia such as due to general diseases and due to some endocrine disturbance.

In large percentage of cases of menorrhagia the cause is some local pathology in the pelvis. One of the classic examples of local disease in pelvis causing menorrhagia is ‘myoma’ and menorrhagia is the characteristic symptom of myomas. Myomatous polypi are found often during diagnostic curettage while investigating the cause of menorrhagia, so are endometrial polypi found sometimes during investigation of menorrhagia. Inflammation of pelvic area like salpingo-oophoritis (inflammation of ovary and Fallopian tube) also can cause menorrhagia by causing hyperemia.

First menstrual period after childbirth and abortion may be excessive because the uterus is enlarged and not involuted properly. Retroversion of uterus also the menstrual bleeding may be in excess. The symptoms of chocolate cyst may also sometime be menorrhagia, which is also may be due to hyperemia induced by the presence of chocolate cyst. Endometriosis generally does not cause menorrhagia, unless the tumor is estrogenic like granulosa cell tumor.

Symmetrical enlargement of uterus (equal to eight to ten weeks of pregnancy), which is generally due to hyperplasia of uterine musculature, may also be the cause of menorrhagia, as is seen in the pelvic examination of patients. The symmetrical enlargement of uterus is due to excessive estrogen stimulation as seen in adenomyosis. Tuberculosis of emdometrium also presents as menorrhagia in the early stage of disease.

Normal blood loss during menstrual cycle is about 50-80 ml and usually do not exceed 100 ml. Menorrhagia is excess menstrual bleeding for longer duration without any alteration in the menstrual cycle i.e. menstrual cycle is unaltered but duration of menstrual bleeding and quantity of menstrual blood loss is increased. Menorrhagia is not a disease itself but a symptom.

The underlying cause of menorrhagia is difficult to detect. But the causes of menorrhagia can be grouped as (a) causes due to general diseases (b) due to local cause in pelvis (c) due to endocrine disturbance and (d) hormonal causes.

Diagnosis of menorrhagia:

1. Finding out the cause of menorrhagia may be very difficult. The patient of menorrhagia must be investigated carefully due to the difficulty in detection of the underlying cause of menorrhagia and its symptoms. History of the patient should be taken carefully to find out the onset, duration, quantity of blood loss, the character of blood and the cyclical feature of menstrual cycle. Any preceding history like recent delivery, abortion or IUCD (intra-uterine contraceptive device) should be elicited.
2. A full gynecological examination should be done, which should include thyroid profile, blood count and bi-manual pelvic examination.
3. A diagnostic curettage should be done to obtain samples for histological examination.
4. Ultrasound examination of should be done to exclude extra uterine pathology.
5. Instead of all the above investigations, if nothing comes out as the cause of menorrhagia, a hysterosalphingogram should be done and it may reveal some cause like polyp, fibroid etc.

Some women experience certain premenstrual symptoms called premenstrual tension about 7-10 days before the start of menstrual bleeding. These premenstrual symptoms include irritability, malaise, lassitude, headache, gastrointestinal upset like constipation and spasm of colon, feeling of fullness of the breasts and abdomen, frequency of urination etc. There may also be feeling of congestion in the feet and face. In some women these symptoms become exaggerated and form a well marked psychosomatic disorder.

In some of the cases of premenstrual tension water retention can be demonstrated by an increase of body weight up to 5 kilos which is accompanied by pedal edema. This is more marked if the patient has history of phlebothrombosis. The fullness of breasts can be prominent symptom and can be accompanied by breast tenderness. On examination of breasts, there is hardness and lumpy feeling and there is also tenderness. Some women with premenstrual tension suffer from migraine headache which disappear if the woman become pregnant.

The cause or etiology of premenstrual tension is not clear. It is suggested (but not proved) that premenstrual tension may be due to excess production of estrogen and abnormal or disturbance in adrenal function, because there is always an increase of extra-cellular water throughout the body. This is because estrogen is recognized to cause water and sodium retention as seen in carcinoma of prostate, where there is excess production of estrogen. But presence of large amount of estrogen does not always produce water retention as seen in granulose cell tumor. Adrenal cortical steroids and progesterone (progesterone containing oral contraceptive pills may are well known for their water retention properties) can also cause water retention, so it may not be always due to estrogen excess.

The exact cause of spasmodic dysmenorrhea is not known. The pain is due to spasm of the muscles and severe enough to cause ischemia or loss of blood supply to the particular area. The following factors are considered to be causative:

• Cervical Obstruction: Obstruction of the cervix can cause severe pain but it is very rare. The pin-point os and narrow cervical canal are associated with anteverted uterus or retroverted uterus and can cause delay in passage of menstrual blood and clot. Surgical dilation of the cervix sometimes relief the menstrual pain. If there is any anomaly in uterus like unicornuate or bicornuate uterus can also cause spasmodic dysmenorrhea.
• Psychogenic causes of dysmenorrhea: the incidence of spasmodic dysmenorrhea is commonest among affluent women and pain is always exaggerated when undue concern is shown by the concerned relatives. Women have lower pain threshold (feel more pain with the same stimulus of pain) and due to predisposition of undue fear and anxiety is more susceptible to dysmenorrhea.
• Endocrine causes: dysmenorrhea is associated to ovulatory menstrual cycles. Women who are taking oral contraceptive pills are rendered anovulatory and thus they do not get spasmodic pain is the proof that endocrines play an important role in the causation of spasmodic dysmenorrhea. Progesterone can stimulate contraction of the muscle layer of the cervix and can cause narrowing of the cervical canal. Progesterone can also stimulate the production of prostaglandin F₂? which can also aggravate the pain.
• Nervous system causes: It is suggested that muscle spasm of uterus may be due to imbalance of autonomic nerve supply to the uterus. Surgical resection of the pre-sacral nerve, which supply uterus can relieve the pain during menstruation. But there is no evidence of motor nerve involvement at present.

IUCDs (intra uterine contraceptive devices) can also cause spasmodic type of pain (spasmodic dysmenorrhea) due to cramps of the uterus by the foreign body or due to increased secretion of prostaglandins. The reason of excess secretion of prostaglandins (F₂?) is not clear while using IUCDs, but this is the main reason of spasmodic dysmenorrhea.

Spasmodic Dysmenorrhea (severe pain) generally does not become manifested until few years (2 to 3 years) of menarche although there may be discomfort associated with menstrual periods.

For some patients the menstrual period is painless till the age of 18 or 19 years and than suddenly severe menstrual pain develops. This is of great importance, because the menstruation before the start of severe pain in these patients is due to estrogen withdrawal and the menstrual cycles are anovulatory (no ovulation takes place). The fact is that, when the menstrual cycles become very painful, they can be made painless by preventing ovulation by giving estrogen. So it can be concluded that this severe pain during menstruation is due to secretion and withdrawal of progesterone. The most severe form of spasmodic pain is seen in patients between ages of 19 to 21 years. It is rare to see a case of severe spasmodic pain after the age of 35 years. The reason is unknown but the pain may persist till menopause though excruciating pain reduces after the age of 35 years.

Spasmodic dysmenorrhea can be generally cured by pregnancy and exception to this is very rare. A woman who has one child has much more chance of having spasmodic dysmenorrhea than a woman who has several children. Spasmodic dysmenorrhea can be cure by marriage and almost all the women report that they have not suffered much after marriage. But it is too optimistic to advice “therapeutic marriage” (advising to get married to cure spasmodic dysmenorrhea). So it is not wise to advice marriage to a patient of spasmodic dysmenorrhea and to have children. The doctor also should consider the fate of unfortunate male victim of “therapeutic marriage”.

The women who are sterile do not suffer from spasmodic dysmenorrhea. The anovulatory cycles are painless and that is why sterile women do not suffer from of spasmodic dysmenorrhea. It is not uncommon to have some degree of menstrual irregularity in case of spasmodic dysmenorrhea. The menstrual loss is also less than usual and some times the menarche may be delayed.

Out of the three main types of dysmenorrhea, spasmodic dysmenorrhea is the most common type. It is said that almost half of adult female population suffer from varying degree of spasmodic dysmenorrhea at some time of their life. But only 10% of them will seek medical attention for the problem. It is generally taken that if a patient’s main problem is dysmenorrhea than it is spasmodic dysmenorrhea. This is because the main symptoms of other two types of dysmenorrhea are not dysmenorrhea but abdominal pain, menorrhagia etc.

The clinical symptoms of spasmodic dysmenorrhea are characteristic and the pain starts on the first day of menstrual bleeding, when severe excruciating lower abdominal pain is felt that last for a short time of approximately 30 minutes to one hour. This pain is severe and intermittent and spasmodic in nature and can lead to nausea, vomiting, fainting and collapse. Sometimes there may be mild shock if the pain is very severe. This initial severe pain of short duration is followed by less severe type of pain that is felt in the lower abdomen, pelvis and sometimes down in the antero-medial aspect of thigh. This pain usually lasts for less than 12 hours.

But there can be variation of symptoms mainly pain in spasmodic dysmenorrhea, to a great extent and it should be realized. Sometimes severe discomfort may start a day before menstrual flow and may persist for more than 12 to 24 hours. The premenstrual pain is felt in the back or in the lower abdomen and lead to excruciating pain felt during first day of menstruation. The presence of premenstrual pain does not mean it is congestive dysmenorrhea, but this a variation of spasmodic dysmenorrhea. The severity of pain very greatly, sometimes it causes extremely severe pain causing shock and incapacitating the woman from her employment. The severity of pain can be determined by asking the patient about vomiting, fainting and degree to which the woman is incapacitated.

Membranous dysmenorrhea can be regarded as extreme form of spasmodic dysmenorrhea. Though it is a severe medical condition, fortunately it is very rare. Membranous dysmenorrhea usually runs in families and can recur after pregnancy.

Membranous dysmenorrhea is accompanied by passing of membranes that may take form of cast in the uterine cavity and microscopically the casts have the appearance of the endometrium of uterus during menstruation except that the disintegrative processes are ill defined. Most likely it is due to deficiency of the tryptic ferment secreted by the endimetrium in normal menstruation. But normal women can pass small membranes during menstruation who are not suffering from Membranous dysmenorrhea. Usually there are no inflammatory infiltrations of tissues of the casts and there is no reason to suspect that Membranous dysmenorrhea is due to chronic inflammation of the uterus.

The treatment of membranous dysmenorrhea is same as that of spasmodic dysmenorrhea. Patient should be educated on the subjects of menstruation and sex education and reassured. Patient should be advised nutritious diet, regular exercise, correction of constipation and inculcation of regular healthy habits. Simple analgesics like aspirin or Buscopan, hormonal contraceptives, prostaglandin synthetase inhibitors like mefanamic acid, danazol etc. are used in treatment of Membranous dysmenorrhea. Surgical dilatation of cervix is also done in many cases. In extreme cases hysterectomy (surgical removal of uterus) is reserved if the patient has completed her family or not desirous of having child any more. Despite all these treatments, the prognosis of Membranous dysmenorrhea is worse than spasmodic dysmenorrhea (except hysterectomy).

Congestive dysmenorrhea is premenstrual pain in lower abdomen or back and is generally seen among sedentary women. Congestive dysmenorrhea usually occur between three to five days (some times more than five days) before starting of menstruation and is always relieved by menstrual flow (pain goes away once menstruation starts).

Congestive dysmenorrhea should be regarded as a symptom of pelvic disease at first instance and there may be some pelvic abnormality in patient with congestive dysmenorrhea. Disease like pelvic adhesion, salpingo oophoritis (inflammation of ovary and Fallopian tube), parametritis etc almost always produce congestive dysmenorrhea and this may be due to hyperaemic ovaries and covered by adhesion from inflammatory lesions. These lesions become tense during premenstrual period of menstrual cycle and cause pain. Congestive dysmenorrhea is also common symptom of certain diseases like myomas, adenomyoma, acquired retroversion of the uterus, chocolate cyst of ovaries etc. But all the patient of congestive dysmenorrhea does not have an organic disease and an example of congestive dysmenorrhea without an organic disease is premenstrual tension or premenstrual congestion syndrome.

Some patients with congestive dysmenorrhea get symptoms (pain and discomfort) referred to one of the iliac fossa usually left iliac fossa. Pain and discomfort is usually accompanied by disturbance in bowel habit (generally constipation and rarely diarrhea) and flatulence distension of abdomen (upper colon) which is due to spasm of some part of colon. Colon is palpable as a tender part of intestine in this situation. Diagnosis can be confirmed by barium enema and radiology. Frequently laxatives are taken with the mistaken idea that purgation will relieve the spasm but in reality it aggravates the condition.

The right management of this type of congestive dysmenorrhea is correct diet (avoiding carbohydrates), avoid purgatives and some anti spasmodic medicines that acts on bowel like Buscopan. These patients of congestive dysmenorrhea should be encouraged to do regular exercise as the patients are generally sedentary office worker.