Women’s Health

Dysmenorrhea is pain during menstruation or painful menstruation. It is crampy lower abdominal discomfort that starts with the beginning of menstrual bleeding and gradually decreases over the next 12–72 hours. There may be nausea, diarrhea, fatigue, and headache and can be seen in 60% to 93% of adolescents in Western countries. beginning with the establishment of regular ovulatory cycles. It is one of the most frequent gynecological problems among women. There are reasons for the scientists to believe that dysmenorrhea increases with degree of civilization in a community.

Severe form of dysmenorrhea is most common among single women, who live sedentary lifestyle. Dysmenorrhea has some economic implication among women who suffer from it, as patients are often incapacitated from work for one or more days during every menstrual cycle. Its prevalence becomes less frequent after pregnancy and also after use of oral contraceptive pills.

Dysmenorrhea should not be regarded as a serious problem but it need to be treated adequately and its treatment is of great importance. Great importance should be given to its treatment due to its economic importance (interruption in the source of income), social life importance and also its psychological importance.

Dysmenorrhea is classified into three different groups and these three groups are:

-Congestive dysmenorrhea.

-Spasmodic dysmenorrhea.

-Membranous dysmenorrhea.

Dysmenorrhea can also be classified into two groups, primary dysmenorrhea and secondary dysmenorrhea.

Infrequent menstruation: It is a condition where intermenstrual cycle is prolonged to more than normal 28 days. But some women have a perfectly normal menstrual cycle at 35 days, without any problem because their fertility is intact and that is why it can not be considered as pathological.

Infrequent menstruation should be diagnosed only if the menstrual cycle is erratic and unduly prolonged and some times it prolonged to three months to four months or longer. This situation is most commonly seen at the time of menarche (first menstruation) or at the time of menopause and which can be regarded as modified amenorrhea. But normal reproductive capacity is possible within this infrequent menstrual cycle and infrequent ovulation.

In the pathological variety of infrequent menstruation the causes and finding on clinical and investigational findings are to some extent similar to amenorrhea and patient is usually obese, poorly developed secondary sexual characters, hirsute, and hypoplasia of genitals. And the most common finding in the investigation of these types of patients is subnormal functioning of ovaries.

Scanty menstruation:

In some women the menstruation lasts for only a day or two and the blood loss is also very less and require changing of diapers pf only one or two. Scanty menstruation that occurs regularly is not pathological and they are not infertile as the regularity of menstruation proves normal pituitary ovarian cycle. So if a patient of scanty menstruation has normal secondary sex characters it can be considered normal and no treatment is required, other than reassurance. If scanty menstruation is accompanied by irregular menstruation, it is suggestive of primary or secondary ovarian sub function. Depending on the history of menstruation, the primary or secondary ovarian disorder can be determined (if from the beginning the menstruation is irregular and scanty, it is due to primary ovarian disorder and if it starts later it is secondary cause). If the menstruation become suddenly erratic and scanty or no loss, it is suggestive of premature menopause. Then the treatment is same as primary and secondary amenorrhea. The patient and relatives should be convinced on this to the point of their satisfaction.

There are many causes of secondary pathological amenorrhea and they are listed below:

1. Obstruction (acquired) to the lower genital tract -lower genital tract injury due to operation, chemical burns etc. which can lead to stenosis (narrowing) of cervix and rarely of vagina.
2. Ovarian factors of secondary pathological amenorrhea:

-Polycystic ovarian disease formerly known as Stein-Leventhal syndrome; hyperthecosis ovarii etc.

- Ovarian failure or hypo hormonal amenorrhea.

- Hyper hormonal amenorrhea-due to excess estrogen as seen in metropathia hemorrhagica and may be due to therapeutic use of hormone.

- Ovarian destruction of ovaries by disease (rare cause), radiation or surgical removal of ovaries known as oophorectomy.

- Premature menopause due to auto immune disease or due to ovarian resistance syndrome.

- Masculinizing tumors of ovaries like arrhenoblastoma, adrenal like tumors, hillus cell tumor, masculinizing luteoma etc.

3. Uterine factors:

-Hysterectomy or surgical removal of uterus.

- Destruction of endometrium of uterus due to-genital tuberculosis, attachment due to excess and vigorous curettage after abortion, or due to intra cavity introduction of radium in uterus.

4. Diseases affecting pituitary:

-Basophil adenoma-Cushing’s disease.

- Acidophil tumor- which produce gigantism and acromegaly.

- Oral contraceptive pills and psychotropic drugs that cause hyperprolactinemia.

- Pituitary failure due to cyst, post partum pituitary necrosis (Sheehan’s syndrome), chromophobe adenoma, Simmond’s disease etc.

- Prolactinoma causing hormonal disturbance.

- Psychogenic causes- anorexia nervosa, stress, pituitary shock, vigorous exercise, pseudocyesis etc.

- Suppression of FSH (follicle stimulating hormone) due to persistence of luteotropic hormone as seen in Chiari-Frommel syndrome.

5. Amenorrhea due to chromosomal abnormalities.

6. Nutritional causes- due to extreme obesity or extreme nutritional deficiency.

7. Thyroid causes- hyperthyroidism, late stage of hypothyroidism.

8. Systemic diseases- diabetes mellitus, severe anemia, debilitating diseases like renal disease and fulminanting tuberculosis.

9. Adreno-genital syndrome (adrenal cortical hyperplasia), Addison’s disease (adrenal failure), adrenal cortical tumors.

Primary amenorrhea can be defined as amenorrhea (menstruation fail to start) at the age of 16 years or amenorrhea at the age of 14 years in presence of well developed secondary sex characters. There are many causes of primary pathological amenorrhea and they are illustrated below:

1. Primary pathological amenorrhea can be there in presence of congenital obstruction of lower genital tract like non canalization of cervix, vagina and imperforate hymen that leads to cryptomenorrhea (occurrence of menstrual symptom without external bleeding). Cryptomenorrhea is not actual primary amenorrhea as the patient is actually menstruating without external visible bleeding.
2. Congenital absence of uterus and gross hypoplasia of uterus can cause amenorrhea.
3. In Turner’s syndrome due to congenital aplasia of ovaries (streak ovary).
4. Inter sexuality like pseudohermaphroditism can cause pathological primary amenorrhea.
5. Hypothyroid cretinism, hypopituitary dwarfism and hypothalamic gonadotropin releasing hormone deficiency cause primary pathological amenorrhea.
6. Organic brain lesions like brain tumors and infection in the brain can lead to primary amenorrhea.
7. Some times delayed puberty is cause of primary amenorrhea.
8. Kallman syndrome, Rokitansky-Hauser-Kuster symdrome etc can cause primary pathological amenorrhea.

All these are causes of primary pathological amenorrhea.

Menstruation is seen in women only during child bearing age of life. Menstruation is absent before puberty, after menopause, during pregnancy and lactation. During pregnancy some women have regular slight bleeding in the early months of pregnancy and during lactation many women menstruate even if they are feeding their child.

All the cases of amenorrhea should be investigated thoroughly and carefully to exclude pregnancy. Pregnancy is the commonest cause of amenorrhea and it should be ruled out positively before making other diagnosis of the cause of amenorrhea. Some times if menopause is started earlier than normal age of menopause, than menopause can be a problem in finding out the cause of amenorrhea. And sometimes women get obsessed that they are pregnant and this clinical condition is known as “pseudocyesis”. This may pose a considerable problem in convincing the woman that she is not pregnant.

All the cases of amenorrhea must be thoroughly investigated after excluding pregnancy. All the types of physiological amenorrhea are self explanatory and easy to diagnose except menopause. Menopause can pose a problem if it starts earlier than it should be.

Except physiological amenorrhea (before puberty, pregnancy, lactation and menopause) mentioned above, all other amenorrhea are pathological amenorrhea.

Amenorrhea is the absence of menstruation. Amenorrhea can be and has been customary to divide into physiological amenorrhea and pathological amenorrhea. Physiological amenorrhea is self explanatory and easy to find out the cause. History reveals the cause of physiological amenorrhea. But pathological amenorrhea is quite difficult to find out the cause. Thorough examination and knowledge of endocrinology is essential in the diagnosis of pathological amenorrhea. The cause of amenorrhea may be quite easy to identify, but sometimes it may be very difficult to detect, than a complete investigation is required including hormone assay.

Primary amenorrhea can be defined as absence of menstruation by the age of 16 years or in presence of well developed secondary sex characters menstruation do not start by age of 14 years. Secondary amenorrhea can be defined as amenorrhea of 6 months or more in a woman with previously normal menstruation, in absence of pregnancy.

Amenorrhea is classified as mentioned before into physiological amenorrhea and pathological amenorrhea:

Physiological Amenorrhea: Physiological amenorrhea includes (a) pre pubertal (before puberty there is no menstruation in females), (b) pregnancy (during pregnancy menstruation stops due to growing of fetus inside uterus), lactation (during lactation for first 3-4 months there is no menstruation, but sometimes pregnancy can occur at this time with out presence of menstruation and this is due to maturation of ovum in absence of menstruation), post menopausal (menopause is permanent and complete stoppage of menstruation). All the physiological amenorrheas are self explanatory.

Pathological amenorrhea is classified into primary and secondary causes.

“Menstruation is the funeral process for the unfertilized ovum” is how some people explain the menstruation. If the fertilization occurs there is no menstruation for as long as the child is not born.

The beginning of menstruation in a woman is called menarche. In healthy women the menstruation starts between the ages of 12-14 years and persists throughout the reproductive life till menopause sets. The average duration of menstrual cycle is of 28 days and duration of blood flow is about 4-6 days. The length of menstrual cycle may be few days more or few days less than 28 days. The menopause sets normally between the ages of 45 to 52 years.

It is quite common for departures from the normal sequences that occur in women who are otherwise can be called healthy and for this minor departures are not considered pathological. Depending on racial factors, nutritional status, geographical conditions, environmental influences and indulgence of strenuous physical activity there may be minor variation in menstrual cycle and the age of onset of menarche.

Among the commonest gynecological problems of women, the menstrual disorders are on the top of the list. Sometimes the menstrual disorders are just symptomatic and despite a thorough search to find out the cause, it can not be found. At that time it becomes quite difficult to manage these problems and has to be treated symptomatically.