MENSTRUAL DISORDERS - MENORRHAGIA AND DYSMENORRHOEA

By Deden Sura Agung

Abnormalities of menstruation is most reason for women to visit obstetricians and gynecology, and menorrhagia are the most frequent cause in women with iron deficiency anemia in the western world. Menstrual disorders can be found abnormalities of blood ejected from the amount or duration of bleeding that occurs each cycle. Menstrual abnormalities 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. His definition is a state of menstruation are not acquired more than 6 months (not in a state of pregnancy). Amenorrhoea can be divided into:

1. Primary amenorrhoea, if a woman never got a period until the age of 16 years.
2. Secondary amenorrhoea is the absence of menstruation for more than 6 months in women who usually have irregular menstrual cycles or up to 12 months in women who usually experience oligomenorrhoea.

The cause of amenorrhoea is known to date are:

1. Physiological; prepubertal, gestation, lactation, Postmenopouse.
2. Pathological; Congenital testicular feminization, the absence of the uterus, imperforate hymen.
3. Hipotalamic; Congenital - Kallman's syndrome, Learned - weight loss, excessive exercise, craniopharyngioma.
4. Pituitary; Tumor - prolactinoma, Infarction - Sheehan's syndrome, Iatrogenic damage - surgery, radiotherapy.
5. Ovary; Congenital - gonadotropin receptor abnormalities, ovarian resistance syndrome, ovarian dysgenesis, Learned - radiation, chemotherapy, surgery, autoimmune disease.

As for amennorrhoea primer, because:
Delay Puberty, familial, nutritional, Delay adrenarche, Congenital structural abnormalities, imperforate hymen, Absence of the uterus or vagina (chromosome abnormalities).

The successful management of amenorrhoea depends on accurate diagnosis and assessment of patient needs. Patients should be given an explanation of fertility problem, hirsutism, delayed secondary sexual development and protection against osteoporosis. In addition to history and thorough physical examination, investigations are also needed, especially those leading to endocrine disorders.

Therapy
Women with ovarian disorders requiring sex steroid hormone therapy with estrogen and progesterone are periodic. Estrogen deficiency can adversely impact 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 to hormone replacement therapy that can improve fertility in patients with ovarian disorders.
In women with low concentrations of gonadotropins required ovulation induction with gonadotropin therapy.

MENORRHAGIA
Are spending too much blood and is usually accompanied by blood clots during menstruation, occurs in menstruation with regular cycle. Normal amount of blood ejected each period is about 50 ml, but the upper limit of normal menstrual bleeding was 80 ml​​. Causes of menorrhagia can be divided into four categories:

1. Coagulation Disorders, The 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 lower the amount of blood loss significantly. However, excessive menstrual bleeding can also be found on the state of the normal coagulation system.
2. Dysfunctional Uterine Bleeding, Is abnormal bleeding from the uterus (long, frequency, amount) that occurs within and outside the menstrual cycle, with no organ abnormalities, hematological and pregnancy, and an abnormal process of hypothalamic - pituitary - ovarian.
3. Suspected menorrhagia associated with uterine fibroids, pelvic infections, endometrial polyps, foreign bodies such as an intrauterine device, myometrial hypertrophy and vascular abnormalities.
4. Medical Disorders, Menorrhagia associated with various endocrine disorders such as Cushing's disease hipothiroidism and although the mechanism 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. A symptom complex, accompanied by cramps in the lower abdomen. Pain radiating to the back and legs, and usually accompanied by gastrointestinal disorders, neurological and malaise. Pain may be felt before, during and after menstruation. Could be colic or continuously. 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 (uterine hyperactivity, endothelins, prostaglandins, vasopressin).
2. Secondary Dysmenorrhoea. This situation can be associated with abnormalities of the pelvis and uterus such as fibroids, IUDs, 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 eliminate the pain.

To search for 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. Similarly Asked postkoitus pelvic pain and bleeding. Risk factor for endometrial carcinoma such as the use of tamoxifen, estrogen therapy, polycystic ovary syndrome and obesity should always be sought in the diagnose. On physical examination may be obtained hipoparatiroid symptoms, anemia or blood clotting disorder. Abdominal and pelvic examination is mandatory in patients with complaints 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 needed. Examination of TSH and T4 are not absolutely necessary, unless there are other things that lead to a state of thyroid disorders. Besides intra-uterine examination is also necessary to assess the direction of malignancy, which is usually found in women over the age of 45 years with irregular bleeding and acquired risk factors.

MENORRHAGIA AND DYSMENORRHOEA MANAGEMENT
Management that existed at the time is divided into three parts, namely:

1. Non-hormonal (synthetic prostaglandin inhibitors, antifibrinolitik and ethamsylate). Antifibrinolitik commonly used is that tranexamic acid can 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 chosen for menorrhagia. The principle works is to decrease the concentration of endometrial prostaglandins. The drugs are usually used mefenamic acid, but keep in mind the side effects of gastrointestinal disorders such as dyspepsia syndrome, nausea and diarrhea. Ethamsylate believed to decrease capillary fragility of the endometrium, 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 thus suppress endometrial glands are depleted and epithelium and decidual transformation that is formed thinner. There are several types of cyclic progesterone as progesterone, progesterone or progesterone intrauterine sustainable. In addition progesterone may also be given estrogen-progesterone combinations 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.