MENSTRUAL PERIODS, ABNORMAL DESCRIPTION: Profuse or extended menstrual bleeding.

CONSIDERATIONS: The menstrual cycle is not the same for every woman. Normal menstrual flow occurs about every 28 days, lasts about 5 days. Produces a total blood loss of 60 to 250 milliliters (2 tablespoons to about 1 cup). Periods may be regular, irregular, light, heavy, painful, pain-free, long, or short, and still be normal. Variation in the menstrual cycle is medically less significant than bleeding, pain, or discharge between periods. Bleeding may be something to worry about for women over age 50 (postmenopausal) or younger than age 12 (prepubertal). The risk of malignancy increases with age. WHAT TO LOOK FOR ?

Make sure that bleeding is coming from the vagina and not from the rectum or in the urine.

This can be accomplished by inserting a tampon into the vagina to confirm that the vagina is the source of the bleeding. COMMON CAUSES: anovulation (failure of ovaries to produce, mature, or release eggs) endometrial polyps endometrial hyperplasia and cancers uterine fibroids abnormal thyroid or pituitary function

WHAT ADVICE SHOULD BE GIVEN TO PATIENT : Bed rest may be recommended if bleeding is heavy.

 The number of pads should be recorded (so that the doctor can determine the amount of bleeding). Change pads regularly, at least twice a day.

Because aspirin may prolong bleeding, it should be avoided if possible. For menstrual cramps, use Mefanamic acid (Anti prostaglandin) for example, Ponstan.

Mefanamic Acid is usually more effective than aspirin for relieving menstrual cramps.

If the patient uses an IUD for birth control, slight spotting is normal. If no other symptoms are present, the spotting is probably insignificant.

EDUCATE YOUR PATIENT TO INFORM YOU ABOUT : If there is severe pain, or if periods have been heavy and recurrent over 3 or more months. If there is bleeding after menopause. If there is abnormal bleeding accompanied by other symptoms. WHAT TO LOOK FOR IN THE PATIENTS HISTORY: The medical history will be obtained and a physical examination performed. Medical history questions documenting abnormal menstrual periods in detail may include: MENSTRUAL HISTORY Are you a woman presently in a menstruating age group? Was the previous menstrual period a normal amount? Do you use tampons? Do you normally have regular periods? QUALITY Has there been passage of blood clots? How long per menstrual period is the bleeding? How heavy is it? TIME PATTERN

When was the last menstrual period? What was the age at which you had your first menstrual period? How long have you had the same menses pattern? AGGRAVATING FACTORS Do you use birth control pills? Do you take an estrogen supplement? Do you use an IUD for birth control? Do you take aspirin more than once per week? Do you take Coumadin, heparin, or other anticoagulant? Has there been a recent childbirth, surgery on or near the vagina or uterus, vaginal infection, uterine infection, or other possible source of trauma to the vagina or uterus? OTHER What other symptoms are also present? Is there abdominal pain? Is there pelvic pain? Is there morning nausea or vomiting? Is there a growth or lump on the genitals? Is there a genital lesion? Is there known pregnancy? Are you vomiting blood? Is there blood in the stools? Is there bleeding into the skin or easy bruising?

The physical examination may include a pelvic examination if the patient is in the premenstrual phase of the menstrual cycle (particularly if endometriosis is suspected). Uterine blood loss can be estimated if the patient knows how many sanitary napkins or tampons were used during a period. Diagnostic tests that may be performed include: Pap smear (if bleeding is inactive) endometrial biopsy pelvic ultrasound

 lab tests such as thyroid function tests, CBC, pregnancy test INTERVENTION: Mefanamic Acid (Ponstan) or another prostaglandin inhibitor is often prescribed. In some cases of heavy bleeding, dilation and curettage ("D and C") may be required. A hysterectomy may not be performed if having difficult periods is the only complaint. If a tumor is found, surgery will sometimes be needed, but the common "fibroid" tumor (uterine fibroids) will often stop growing by itself, and surgery may not be needed depending on the amount of bleeding and the response to various treatment attempts. Such tumors often grow slowly and stop growing completely at the menopause, so an operation can be avoided by waiting. However, if the Pap smear is positive, surgery or other type of therapy may be necessary. If the heavy bleeding is related to hormonal abnormalities, treatment of the specific abnormality will correct the bleeding. Female hormones (birth control pills or progestins) are commonly used to regulate menses.

Menstruation, painful Content Description: Menstruation that is accompanied by either sharp, intermittent pain or dull, aching pain in the pelvis or lower abdomen. Considerations: Painful menstruation affects over half of menstruating women and is the leading cause of lost time from school and work among women of childbearing age. This pain may precede menstruation by several days or may accompany it, and usually subsides as bleeding tapers off. Some pain during menstruation is normal; excessive pain is not. Dysmenorrhea refers to menstrual pain severe enough to limit normal activities and require medication. There are several types of dysmenorrhea: Primary dysmenorrhea refers to menstrual pain that occurs in otherwise healthy women. Prostaglandin activity is thought to be a causative factor because prostaglandin levels have been found to be much higher in women with dysmenorrhea than in women who experience only mild or no menstrual pain. Secondary dysmenorrhea is menstrual pain that is attributed to some underlying disease process or structural abnormality either within or outside the uterus (for example, pelvic inflammatory disease, fibroids, endometriosis, adhesion, or uterine displacement). Endometriosis is the most common cause of secondary dysmenorrhea and is frequently misdiagnosed as primary dysmenorrhea. Psychogenic dysmenorrhea may be attributed to emotional stress or true anxiety. It can also be caused by a lack of information regarding menstruation or negative attitudes about the process passed from mother to daughter. Membranous dysmenorrhea is intense cramping caused by passage of endometrial (uterine lining) tissue being passed through an undilated cervix. This condition is quite rare. The presence of an IUD (intrauterine device for contraception) may also be a potential cause of menstrual pain.

The incidence of menstrual pain is greatest in women in the late teens and twenties, then declines with age. It does not appear to be affected by childbearing. An estimated 10 to 15% of women experience menstrual pain each month severe enough to prevent normal daily function at school, work, or home. The majority of women will suffer this degree of disability at least once during their reproductive years. Increased risk is associated with younger age, IUD use, multiple sexual partners, and past medical history of any of the conditions associated with secondary dysmenorrhea. Common Causes: premenstrual syndrome (PMS) intrauterine devices (IUDs) used for birth control discontinuation of birth control pills stress and poor health pelvic inflammatory disease endometriosis Home Care: Ibuprofen or acetaminophen may relieve mild menstrual pain. Antiprostaglandins are quite effective in the management of moderate to more severe pain. These include higher doses of aspirin, as directed by a health care provider. However, this is sometimes hard for patients to tolerate. Other nonsteroidal anti-inflammatories may be used; ibuprofen is the most common. To work effectively, these medications must be taken at the first appearance of symptoms. Some women experience several days of pain which may require the use of narcotic pain relievers such as codeine. Some relief may be provided by applying a heating pad to the abdomen, effleurage (a light circular massage with the fingertips), drinking warm beverages, taking a warm shower, performing waist-bending and pelvic rocking exercises, and walking. Emotional support, psychological counseling, or antidepressants may be helpful for those women who have inadequate relief of chronic pain. If pain continues, consult your health care provider. Call If: the pain is severe. menstrual periods always hurt, or if other unexplained symptoms accompany the pain.

What to Expect: The medical history will be obtained and a physical examination performed. Medical history questions documenting your symptom in detail may include: menstrual history Are you a woman presently in a menstruating age? Are you sexually active? Do you use birth control? What type? quality Was the previous menstrual period a normal amount? Do you use tampons with menstruation? Do you normally have regular periods? Do you have heavy menstrual bleeding (menorrhagia)? With passage of blood clots? Do you have prolonged menstrual bleeding (more than five days per menstrual period)? Describe the pain (sharp, dull, intermittent, constant, aching, cramping). time pattern When was the last menstrual period? What was the age at which you had your first menstrual period? How long have you had the same menses pattern? When did you begin to have painful menstruation? Is it getting worse or better? When in your menstrual cycle do you experience the pain? relieving factors What have you done to try to relieve the discomfort? How effective was it? What has been effective in the past for you? other What other symptoms are also present? The physical examination will probably include a pelvic examination. Diagnostic tests that may be performed include: dilation of the cervix (see D&C procedure) laparoscopy

cultures (may be taken to rule out sexually transmitted diseases such as gonorrhea, primary syphilis, or Chlamydia infections) CBC sed rate RPR Intervention: Oral contraceptives may be prescribed as an attempt to alleviate menstrual pain. If not needed for contraception, they may be discontinued after 6 to 12 months. Many women note continued freedom from symptoms despite stopping the medication. Surgery may be indicated for those women unable to obtain adequate pain relief or control. Procedures may range from removal of cysts, polyps, adhesions, or fibroids to complete hysterectomy in cases of extreme endometriosis. Prescription medications may be used for endometriosis. For pain caused by IUD, removal of the IUD and alternative birth control methods may be needed. Antibiotics may be indicated for pelvic inflammatory disease. After seeing your health care provider: You may want to add a diagnosis related to painful menstruation to your personal medical record.