MENSTRUATION DISORDERS

By Deden Sura Agung

Abnormalities of menstruation is most reason for women to visit obstetricians and gynecologists, and menorrhagia are the most common cause in women with iron deficiency anemia in the western world. Menstrual abnormalities that were found to be abnormalities of the amount of blood removed or duration of bleeding that occur each cycle. Menstrual disorders that can be encountered is amenorrhoea, oligomenorrhoea, menorrhagia and dysmenorrhoea.

AMENORRHOEA

A symptom of ovarian dysfunction and reproductive systems are usually associated with infertility problems. Definition is the state does not obtaining menstruation more than 6 months (not in a state of pregnancy). Amenorrhoea can be divided into:

1. Primary Amenorrhoea, if a woman never gets menstruation until the age of 16 years.

2. Secondary Amenorrhoea is the absence of menstruation for more than 6 months in women who usually get a regular menstrual cycle or can be up to 12 months in women who usually experience oligomenorrhoea.

The successful management of amenorrhoea depends on the accuracy of diagnosis and assessment of patient needs. Patients should be given an explanation of fertility problem, hirsutism, delayed secondary sexual development and protection against osteoporosis. Besides anamnesis and thorough physical examination, investigation is also needed, particularly those leading to endocrine disorders. Here is the algorithm evaluation in women with amenorrhoea.

THERAPY 

Women with ovarian disorders require sex steroid hormone therapy with estrogen and progesterone are periodic. Estrogen hormone deficiency may be detrimental to bone and blood vessels, and therefore there is a suspicion in women with Turner syndrome was not optimal bone growth and higher risk for fracture. In addition, replacement hormone therapy can improve fertility in patients with ovarian disorders. In women with low gonadotropin concentrations are needed ovulation induction with gonadotropin therapy.

MENORRHAGIA

Are spending too much blood and is usually accompanied by blood clots during menstruation, occurs on a regular menstrual cycle. Normal amount of menstrual blood are removed each is about 50 ml, but the upper limit of normal menstrual bleeding is 80 ml. Causes of menorrhagia can be divided into 4 categories: A coagulation disorder, incidence of menorrhagia is closely linked to conditions such as thrombocytopenic purpura and von Willebrand's disease. In women with thrombocytopenia, excessive menstrual blood can be attributed to the low number of platelets that is when menstruation occurs. In these circumstances, splenectomi known to reduce the amount of blood that comes out with a significant. However, the discharge of excessive menstrual blood can also be found in the normal state of coagulation system. Two dysfunctional uterine bleeding (PUD) is abnormal bleeding from the uterus (long time, frequency, amount) that occurs within and outside the menstrual cycle, with no organ abnormalities, hematological and pregnancy, and is the process of hypothalamic disorders - pituitary - ovarian. PUD can be divided into 2 PUD, PUD ovulation and anovulation.

 - PUD ovulation, is an idiopathic bleeding. Found that there are some products that alter endometrial vasoconstriction and the effect on the amount of bleeding when menstruation.

- PUD anovulation, usually due to an inadequate signal, for example in polycystic ovarian disease or in the premenopausal state. Could also be due to an interruption in such a positive feedback system in children.

3 suspected menorrhagia associated with uterine fibroids, pelvic infections, endometrial polyps, foreign bodies such as the intrauterine device in the uterus, myometrial hypertrophy and vascular abnormalities. 4 medical disorders, menorrhagia associated with various endocrine disorders such as Cushing's disease hipothiroidism and although the mechanism of occurrence is unknown. If thyroid disease is the cause, need to look for other symptoms such as abnormal weight gain, hair loss and constipation.

DYSMENORRHOEA

Dysmenorrhoea means painful menstruation. Is a complex phenomenon, accompanied by cramps in the lower abdomen. Pain radiating to the back and legs, and usually accompanied by gastrointestinal disorders, neurological and malaise. Pain can be felt before, during and after menstruation. Can be either colicky or constant. Based on the etiology, dysmenorrhoe can be divided into 2 primary dysmenorrhoea and secondary dysmenorrhoea.

1. Dysmenorrhoea primary (idiopathic) There are various theories that explain why women may experience dysmenorrhoea, namely

2. Hyperactivity of the uterus, was first presented in 1932. Since then, studies continue to be done to prove the truth of this theory. Patients often describe the pain like the pain during childbirth, and increased contractility of the uterus can be seen by measuring and comparing the intra-uterine pressure in women with dysmenorrhoea with women who did not experience it.

3. Endothelins represents a potential in the uterus uterotonin women who are not pregnant. Allegedly involved in the contraction of smooth muscle myometrium.

4. Prostaglandins, has been known that women who experienced dysmenorrhoea have increased synthesis of PGF 2 alpha on endometriumnya. No known reason why the level of prostaglandins in this setting increases. Primary Dysmenorrhoea occurred almost always in the cycle of ovulation and steroid hormones thought to affect the concentration of prostaglandins in the uterus and myometrial contractility.

5. Vasopressin contained substances other stimulants in non-pregnant women, such as vasopressin which is a vasoconstrictor which stimulates uterine contractions. It was found that concentrations of vasopressin on the first day of menstruation of women with dysmenorrhoea higher when compared with women who did not. Therefore vasopressin analogue suspected to be an alternative in the management of dysmenorrhoea.

6. Secondary Dysmenorrhoea, this condition can be associated with pelvic and uterine disorders such as fibroids, IUD, PID, adenomyosis, endometriosis or cervical stenosis. The cause of the pain itself is not so clear and the use of inhibitors of prostaglandin synthesis is not very effective to relieve pain. To find the etiology of menorrhagia and dysmenorhoea, required a complete diagnose. Characteristics to look for bleeding. Bleeding a lot, regular, cyclic without any spotting between cycles can lead to dysfunctional uterine bleeding. While the history of progressive pain during menstruation and is accompanied disparenia can lead to endometriosis. Also Asked postkoitus pelvic pain and bleeding. Endometrial cancer risk factors such as the use of tamoxifen, estrogen therapy, polycystic ovarian syndrome and obesity should always be sought in a diagnose. On physical examination may be obtained hipoparatiroid symptoms, anemia or blood clotting disorder.

Abdominal and pelvic examination is mandatory in patients with symptoms of menorrhagia. In the laboratory examination of hemoglobin should not be overlooked when the patient's complaint is menorrhagia, and iron supplementation should be given when necessary. TSH and T4 is not absolutely necessary, unless there are other things that lead to a state of thyroid disorders. In addition, intra-uterine examination is also required to assess the direction of malignancy, which is usually found in women over age 45 years with irregular bleeding and acquired risk factors. The method can be performed to assess the endometrium are:

7. Dilatation and curettage

8. Hysteroscopy

9. Endometrial sampling

10. Ultrasound

MENORRHAGIA AND DYSMENORRHOEA MANAGEMENT

Currently divided into 3 parts:

1. Non-hormonal (inhibitor of prostaglandin synthesis, antifibrinolitik and ethamsylate). Antifibrinolitik commonly used is an acid that can traneksamat reduce menstrual bleeding by 50%. These drugs are quite effective with minimal side effects that depend on the dose. NSAIDs is an inhibitor of prostaglandin synthesis which is the drug of choice for menorrhagia. The principle works is to decrease the concentration of endometrial prostaglandin. The drugs are usually used mefenamic acid, but keep in mind the side effects are gastrointestinal disorders such as syndrome of dyspepsia, nausea and diarrhea. Ethamsylate believed to decrease capillary fragility of endometrial, but not yet widely used because the results vary.

2. Hormonal (progesterone, oral contraceptives and hormone replacement therapy). Synthetic progesterone is used widely for the treatment of menorrhagia. The effect is thus suppress endometrial glands are depleted and epithelium and decidual transformation formed thinner. There are several types of progesterone, cyclic progesterone, sustainable progesterone and intrauterine progesterone. In addition progesterone may also be given estrogen-progesterone combination, such as danazol or GnRH analogues.

3. Surgical treatment. There are several things you can do with the way surgery is hysterectomy, endometrial ablation techniques and endometrial resection transervikal by way of thermal balloon and microwave endometrial ablation.