Menstrual Disorders, Abnormal Uterine Bleeding, Pelvic Floor Relaxation/Dysfunction (PFD), Pelvic Organ Prolapse (POP)

amenorrhea

lack of menstrual cycle

primary amenorrhea

occurs is the girl passes the age by which menses is normally started (15y/o), w/ normal growth & secondary sexual characteristics or w/i 3 years of breast development

secondary amenorrhea

• when established menses (>3 mos) ceases

• most commonly caused by pregnancy

causes of amenorrhea

• hypothalamic dysfunction

  • systemic stress related to marked weight loss (anorexia, bulimia, fad dieting) or excessive exercise (elite athletes, dancers, low body fat)

  • functional hypothalamic amenorrhea

• pituitary dysfunction

  • some anxiety & psych meds

• chronic anovulation or ovarian failure

• anatomic abnormalities

intermenstrual bleeding

bleeding or spotting btwn regular periods

heavy menstrual bleeding

• excessive menstrual bleeding that occurs at regular intervals

• prolonged duration (>7 days) or excessive amount; women’s perception of heavy bleeding

polymenorrhea

frequent regular menses (cycles <21 days)

oligomenorrhea

bleeding occurs < every 35 days; infrequent

dysmenorrhea

painful menses

primary dysmenorrhea

• caused by prostaglandins (HA, nausea, cramps, diarrhea)

  • cramps felt at onset of menses in low back & pelvis

• 2-3 days

• typically disappears after 1st pregnancy

primary dysmenorrhea tx

heat, NSAIDs, hormonal contraception

secondary dysmenorrhea

• pathology of reproductive tract

• onset usually after age 25 or after years of painless cycles

  • endometriosis, PID, cervical stenosis, fibroids, ovarian cysts, tumors of pelvis or abdomen, IUDs

premenstrual syndrome

second half of menstrual cycle anywhere from days to 2 wks prior to the next cycle

dysmenorrhea & PMS tx

• NSAIDs (ibuprofen, aspirin, naproxen) to act as prostaglandin inhibitors

• COCs to inhibit ovulation (less prostaglandins)

• self-care

  • regular exercise, good nutrition, avoid alcohol, rest

  • heat

  • supplements: vit B6, E, calcium, mag

  • herbal: black cohosh, ginger, red raspberry leaf, evening primrose oil

• avoid salt

• increase natural diuretic: asparagus, cranberry juice, peaches, parsley, watermelon

• heat/warm packs

• stress reduction/adequate sleep

vit B6

relieve premenstrual bloating, irritability

vit E

ease cramping & breast tenderness

calcium 1200mg

alleviate physical & psychological sx

magnesium 400mg

bloating

premenstrual dysphoric disorder

• more severe form of PMS

• emotional/behavioral sx

• DSM-5 as depressive disorder

• sx relieved by menses

PMDD tx

• same for PMS

• SSRIs: prozac, zoloft, paxil

mittelschmerz

• mid-cycle ovulatory pain, typically unilateral

• cause r/t follicular rupture & peritoneal irritation from follicular fluid or blood

mittelschmerz sx

• sharp cramp-like pain lasting from few hours to 1-2 days

• light vaginal spotting

mittelschmerz tx

analgesics, reassurance that it’s benign, hormonal contraceptives

endometriosis

• endometrial-like tissue outside of uterus

  • ovaries, fallopian tubes, pelvic peritoneum

• theory caused by retrograde menstruation, immune dysfunction, genetics

• pathophys: adhesions, hormone-responsive, proliferative during cycle —> inflammation, adhesions, scarring

retrograde menstruation

when blood from your period flows backward into your abdomen instead of out your vagina

endometriosis sx

• cyclic pelvic pain (progressive & severe)

• dysmenorrhea

• sx depends on affected area

• dyspareunia

• infertility

• GI sx: diarrhea, constipation, bloating

• rectal pain

endometriosis medical tx

• NSAIDs

• hormonal suppression

  • COCs to suppress endometrial lining proliferation

  • progestins

  • GnRH agonists — hypoestrogenic, pseudomenopausal state

endometriosis surgical tx

• laparoscopic excision or ablation of lesions & adhesions

• hysterectomy & BSO

endometriosis complementary tx

acupuncture, yoga, pelvic PT, massage, chinese herbal meds

pelvic floor relaxation/dysfunction (PFD)

• occurs when muscles, ligaments, & connective tissue (fascia) that support pelvic organs (bladder, uterus, rectum) become weakened, overstretched, or damaged

  • d/t childbirth, aging, hormonal changes, chronic straining, surgery

• can lead to

  • pelvic organ prolapse (POP)

• other PFD types: urinary/fecal incontinence, pelvic pain, sexual dysfunction, obstructed defecation

pelvic organ prolapse (POP)

organs descend into or outside vaginal canal

• cystocele, rectocele, uterine prolapse, enterocele

cystocele

• weakened upper anterior wall of vagina is no longer able to support weight of urine in bladder

• bladder protrudes downward into vagina

• incomplete emptying of bladder

rectocele

• posterior wall of vagina becomes weakened & thin

• straining at defecation

• digital pressure on posterior vaginal wall to facilitate BM

enterocele

• prolapse of upper posterior vaginal wall btwn vagina & rectum

• often contains loop of bowel

uterine prolapse

occurs when cardinal ligaments which support uterus & vagina are stretched during pregnancy & do not return to normal

• 1st degree: uterus remains in vagina

• 3rd degree: cervix extends outside body

uterine prolapse sx

• pelvic fullness

• dragging sensation

• fatigue

• urinary frequency & urgency

• constipation & flatulence

• cervical ulceration & bleeding

uterine prolapse tx

• kegel exercises

• for urinary stress incontinence, meds

• vaginal pessarie or ring (not surgical)

• surgical intervention

fistula

• hole or opening btwn 2 organs

• rectovaginal, vesicovaginal

urinary incontinence

• stress: leakage with coughing, sneezing, exercise

• urge (overactive bladder): sudden urge followed by leakage

• mixed

• first-line interventions: pelvic floor PT, biofeedback, bladder training, behavioral strategies

fecal incontinence

• involuntary loss of stool or gas

• often linked to obstetric injury, aging, chronic constipation, nerve damage

pelvic pain syndrome

• chronic pelvic pain d/t muscle hypertonicity, nerve entrapment, scar tissue

• includes elevator ani syndrome, pudendal neuralgia

obstructed defecation

difficulty evacuating stool caused by paradoxical contraction or poor coordination of pelvic floor muscles

anemia

hemoglobin < 11g/dL

• associated w/ preterm birth & LBW

nutrition deficiency anemia

iron & folic acid deficiency

hemolysis anemia

sickle cell disease & thalassemia

iron deficiency anemia

• dietary iron required to synthesize hemoglobin, affecting O₂ transport

  • difficult to meet pregnancy needs

• most common

• begin pregnancy anemic

  • baby needs O₂ → need more hemoglobin = more iron

• greatest need in second half of pregnancy

iron deficiency anemia maternal s/sx

pallor, fatigue, lethargy, HA, pica

iron deficiency anemia maternal risks

asymptomatic, prone to infection, increased risk of pre-e & PPH, delayed wound healing

iron deficiency anemia fetal/neonate effects

• take from mom → mom at risk for anemia

• reduced fetal red cell volume, hemoglobin, iron stores

• LBW, preemie, stillbirth (severe anemia Hgb < 6g/dL)

iron deficiency anemia management

prevention

• pregnant women start on 30mg/day (PNV) & eat iron rich diet

if diagnosed

• increased 60-120mg PO daily routine supplemental iron therapy

• reevaluate 1mo PP

iron supplementation teaching

• can cause constipation, black stool

  • stool softener? nighttime

• vit C aids in absorption

• calcium or caffeine can inhibit absorption

• take on empty stomach

iron rich foods

meat, fish, chicken, green leafy vegetables

folic acid

cell duplication, fetal & placental growth, RBC formation

• needs double during pregnancy

folic acid deficiency

megaloblastic

• increased risk for neural tube defects

folic acid deficiency anemia prevention

0.4mg/day folate supplement

folic acid deficiency anemia tx

1mg folic acid & iron supplement

folic acid sources

fresh leafy green vegetables, OJ, red meat, fish, chicken, legumes

sickle cell disease

autosomal recessive genetic disorder that causes anemia d/t abnormal hemoglobin, resulting in distortion & destruction of RBC

• worsened by pregnancy changes

sickle cell disease anemia maternal risks

• crisis: sudden attacks of pain (general, localized in bones, joints, lungs, abdominal organs, spine) d/t ischemia from occluded capillaries

• complications: require blood transfusion, infections, emergency c/s, CHF, renal failure

sickle cell disease anemia fetal risks

• fetal death following an attack

• prematurity, IUGR

hepatitis B

A-G, can be transmitted perinatally

hepatitis B modes of transmission

blood, saliva, vaginal secretions, s3men, breast milk that readily cross placental barrier

hepatitis B maternal symptoms

• vomit, abdominal pain, jaundice, fever, rash, painful joints

• most adults recover w/i 6mos, then have immunity

hepatitis B fetal & neonatal effects

• increased incidence of prematurity, LBW, neonatal death

• risk of developing acute hep B infection at birth

• if acquired prior age 5, more likely to become chronic carriers of the disease (reservoirs)

hepatitis B management

• safe sex, universal precautions

• vax

• all pregnant women screened for HbsAg

  • if neg, offer vax

• if pos during delivery, infant should be given w/i 12hrs of birth

  • hep B immune globulin (HBIG)

  • hep B vax (dose 2 at 2-3mos, dose 3 at 6mos)