Ovarian sex hormone secretion is influenced by hypothalamic gonadotrophin-releasing hormone, which stimulates the pituitary gland to release FSH and LH (see Ch. 5). FSH stimulates the initial development of ovarian follicles and their secretion of oestrogen; LH stimulates further follicular development, initiates ovulation and stimulates ovarian hormone production. FSH and LH control the secretion of two ovarian steroid hormones – oestrogens and progestogens.

Uterine tubes

The uterine tubes (10–14 cm long) turn posteriorly as they extend laterally from the cornua (or horns) of the uterus towards the lateral pelvic wall. The ends open as funnel-shaped structures with fimbriae (finger-like projections) (Figure 7.2). The broad ligament of peritoneum forms the outer serous layer of the tubes. The middle coat, of muscular tissue, is arranged in two layers: an outer longitudinal layer and an inner circular layer. The lining mucosa, comprised mainly of ciliated columnar epithelium and secretory cells, lies in folds. The lumen of the tube is narrow. The ends of the tubes are mobile and at ovulation the fimbriae enfold the adjacent ovary to take up the released oocyte.

Functions

The uterine tubes convey oocytes from the ovary to the uterus. They are the site of fertilisation of the oocyte by a spermatozoon. Passage of the oocytes or ova along the tube is facilitated by the action of cilia and peristalsis.

Vagina

The vagina is a fibromuscular channel extending downwards and forwards from the cervix to the labia. The endocervix protrudes into the upper end of the vagina, known as the vault. This creates anterior, posterior and lateral fornices (Figure 7.1). The anterior wall of the vagina is approximately 7.5 cm and the posterior wall about 9 cm in length. The vagina is composed mainly of smooth muscle with a lining mucosa arranged in folds or rugae. Until first sexual intercourse, a fold of mucous membrane, the hymen, forms a border around the external opening of the vagina, partially closing the outlet. Normally the anterior and posterior wallslie in apposition but the vagina is capable of considerable distension during intercourse and childbirth.

The vagina is kept moist during the reproductive years by mucus from the cervix and transudation of fluid through the vaginal wall. Glycogen produced in the vagina is fermented by the bacterium Lactobacillus (Döderlein’s bacillus) (part of the normal flora of the vagina) to produce lactic acid. This maintains a slightly acid environment in the vagina, inhibiting the growth of some other microorganisms.

Pelvic floor

The pelvic floor is formed by tissues that fill the pelvic outlet and support the pelvic organs.

• The levator ani muscles form a broad muscular sheet extending from the pubic bone to the sacrum and coccyx and laterally to the pelvic walls. The urethra, vagina and rectum perforate this muscular sheet.

• The superficial perineal muscles lie under the levator ani muscles. They pass from the pelvic side walls, the pubis and the sacrum to unite centrally between the vagina and the rectum, where they form the superficial part of the perineal body.

• The perineal body consists of wedge-shaped muscle and fibrous tissue lying between the lower vagina and lower rectum.

The menarche

The menarche describes the first menstruation. In Western countries, this usually occurs between 9 and 16 years of age. Nutrition and body weight and composition influence menstruation and sexual development. The onset of menstruation may be delayed by excessive physical activity.

Some oestrogen synthesis stimulates early secondary sexual characteristics to occur some time before the menarche. There may be follicular growth and some oestrogen withdrawal bleeding to give the early periods of the first few months. These cycles are anovular (without ovulation) and such periods are painless. More discomfort may be experienced with menstruation that follows ovulation. A rise in basal temperature may be a guide to whether ovulation has occurred.

Variation in menstrual cycle length occurs in response to significant life events. Excitement, stress, anxiety or change of environment can delay the maturing of a follicle, ovulation and menstruation. Excessive exercise, as in athletes, can result in irregular periods, anovulatory cycles and amenorrhoea.

The climacteric and menopause

The climacteric describes the normal changes that occur leading up to the menopause (cessation of menstruation). The process of the climacteric is usually gradual and may extend over several years. Most women experience the climacteric or perimenopause over a period of 2–3 years, but it may extend longer. During this time the body adjusts to less oestrogen.

The ovaries ‘age’, resulting in ripening of fewer follicles and decreased stimulation by the pituitary hormones. The ovaries atrophy and less oestrogen is released into the circulation. Initially this reduced oestrogen level in the blood results in excessive production of FSH from the anterior pituitary gland, and this feedback mechanism can continue for several years. The withdrawal of oestrogen and the increase in pituitary hormone contribute to the changes associated with the climacteric.

The menopause is marked specifically by the date of the last menstrual period so can only be identified in retrospect some months after the event. The menopause is only one effect of the climacteric. Events occurring after menstruation has stopped for at least a year are termed postmenopausal.

The menopause signifies the end of a woman’s reproductive capacity. This normally occurs between 45 and 58 years of age and in the UK the average age when periods stop is 51 years.

A premature menopause is one which occurs before the age of 40 years. This can occur naturally or may be induced iatrogenically. The age of menarche, socioeconomic factors, race, use of oral contraceptives and number of pregnancies appear to have no effect on whether a woman has an early or a late menopause (Abernethy 2005).

The fluctuations in oestrogen production, while following a gradual decline, alter the menstrual pattern in many women, showing considerable variation amongst women until the menopause.

After the menopause there is continued secretion of oestradiol and oestrone, although in varying and declining amounts. Oestrone becomes the predominant oestrogen. Small amounts of oestrogen can be found in the blood and urine of postmenopausal women.

Information about the disorders associated with oestrogen withdrawal and hormone replacement is outlined in a later section (see pp. 206–208).

Uterine bleeding patterns

The climacteric is characterised by irregular menstruation. Periods may become scanty, or bleeding may be heavy. The menstrual cycle shortens, associated with a decrease in oestradiol secretion. As this continues, LH levels rise and then menstrual cycles lengthen. Anovulatory cycles result in oestrogen-withdrawal bleeding patterns, irregular cycles with intermittent and prolonged spotting (low oestrogen profile) or prolonged amenorrhoea followed by sudden, profuse bleeding (high oestrogen profile).

Somatic changes

Somatic changes are caused by a decrease in oestrogen and an increase in gonadotrophins. Since the diurnal secretion of oestrogen varies from woman to woman, the changes experienced vary in severity but are progressive.

The ovaries atrophy and follicles disappear or fail to respond to gonadotrophins. Other internal reproductive organs become thinner and atrophy. Vaginal mucosa atrophies with a loss of rugae, elasticity and lubrication, and an increase in pH. Vaginal dryness can result in pruritus and dyspareunia. Loss of the acidic environment allows microorganisms to multiply more easily. There is an increase in connective tissue, causing narrowing and shortening of the vagina. The vagina is more prone to ulceration and bleeds easily to touch. Vaginitis may occur in older women. The labia thin and lose their sexual responsiveness. Pubic hair growth decreases with advancing years. The pelvic floor loses tone and elasticity, and become less effective in supporting the pelvic contents. The urethral mucosa may also show atrophic changes, resulting in symptoms of urethritis and cystitis, in the absence of bacteriuria.

Physiological changes, resulting in lack of lubrication, loss of libido and dyspareunia, can contribute to sexual problems for the woman. Hormone replacement therapy (HRT) may be a possible treatment option or psychosexual counselling may be of benefit. Many factors contribute to a satisfying sex life – satisfaction in a relationship, psychological well-being and emotional security can all make a significant contribution, illustrating the need for a holistic approach.

Vasomotor disturbances

Vasomotor disturbances commonly accompany the climacteric. The frequency and intensity of these vary between individuals. Hot flushes/flashes are the most common but perspiration, headache, fainting and palpitations may also be experienced. Hot flushes can start with a sensation of extreme warmth in the chest, quickly followed by flushing of the face and neck. The flush may be accompanied by sweating and palpitations. Dizziness and nausea may also be experienced. Shivering is often reported after the flush, probably due to compensatory constriction of the blood vessels. While vasomotor symptoms will eventually subside with no long-term effects, hot flushes and sweats are embarrassing, uncontrollable and can be distressing for many women. Porter et al (1996) report on a survey of 6096 women aged 45–54 years and note that 84% experienced at least one of the classic symptoms associated with the menopause and 45% of the women reported one or more symptoms as a problem. Randomised controlled trials (RCTs) have indicated the value of oestrogen in reducing the severity of vasomotor symptoms when compared with placebo.

In addition to oestrogen therapy, other treatments, such as vitamin E and/or B₆, clonidine, phytoestrogens, propranolol and oil of evening primrose (contains gamma linoleic acid), have been used. Progestogens have been shown to alleviate hot flushes. Phytoestrogens, found in soya products, have been suggested as a remedy for menopausal symptoms. While some women do find them valuable, there is controversy about advocating them as a therapy for menopausal symptoms (Naftolin & Stanbury 2002).

Emotional changes

These can include anxiety, poor concentration, dizziness, a bloated feeling and depressive feelings after the menopause. In addition to hormonal changes occurring at the perimenopause, women may also be facing other psychosocial changes such as children leaving home which can affect their emotional state.

Menstrual disorders

Amenorrhoea

Amenorrhoea (absence of menstruation) is either primary or secondary. Primary amenorrhoea is the non-appearance of menstruation in a female by the age of 16 years. There may be an anatomical fault or some disturbance in hormonal secretions. Delayed puberty may be familial or constitutional. Secondary amenorrhoea is the absence of menstruation for a period of time which is twice the length of the normal menstrual cycle for a woman who has previously menstruated, i.e. missing two or more menstrual periods. This may result in the woman waiting some time before seeking investigation.

Amenorrhoea is physiological before puberty, during pregnancy and lactation, and after the menopause. Inheritance, race, climate and general nutrition influence the menarche (see above).

Before puberty

A teenage girl may be seen by her GP because of delay in the onset of menstruation. The doctor may undertake a general physical examination to determine if other secondary sex characteristics are present; if so, menstruation will follow in due course. If secondary sex characteristics or menstruation fail to develop, the doctor will refer the patient to a consultant gynaecologist and endocrinologist for investigation.

During pregnancy

Following ovulation, cells of the ovarian follicle are stimulated by LH to develop the corpus luteum which produces progesterone. This hormone stimulates the endometrium and its secretory glands in readiness to receive the fertilised ovum from the uterine tube. When the fertilised ovum embeds in the lining of the uterus (now known as the decidua), it produces the hormone human chorionic gonadotrophin (hCG). This hormone supports the corpus luteum to continue producing progesterone until the placenta is established and producing hormones. The presence of the growing fetus and the continued production of progesterone prevent the loss of endometrium and the menstrual flow.

Amenorrhoea is frequently one of the first symptoms that lead a woman to suspect that she is pregnant. Levels of hCG in the urine provide a positive diagnosis when undertaking a urinary pregnancy test. This can be confirmed by the presence of fetal heart pulsation seen on ultrasound scan (USS) from 5 to 6 weeks’ gestation onwards.

During lactation

Women who totally breast feed their baby may not ovulate or menstruate during the first 6 months after childbirth or until weaning commences. Breast feeding therefore exerts a measure of birth control, but must not be recommended as an effective contraceptive.

Total nipple stimulation is important for suppression of ovarian function. The suckling stimulus to the nipple leads to a neurohormonal reflex production of prolactin by the anterior pituitary gland which inhibits gonadotrophin hormone release, preventing ovulation and menstruation.

Suppression of the ovaries declines where supplements comprise more than 50% of the diet of the baby who is breast feeding. The incidence of ovulation and the risk of pregnancy then rise rapidly.

A poor state of nutrition in the woman can inhibit ovulation, particularly in developing countries. To ensure contraception during the period of lactation, the woman may be advised to use a barrier method. The progestogen-only pill is considered safe during lactation since it does not affect the milk supply and only insignificant quantities enter the milk. However, the combined oral contraceptive pill inhibits lactation.

After the menopause

The menopause, the date of the final menstrual period, may not be fully acknowledged until a year without periods has passed.

Pathological amenorrhoea

There are a number of pathological causes of amenorrhoea.

Ovarian lesions

Failure of normal ovarian development is rare. Chromosomal abnormalities such as Turner’s syndrome may occur (see Ch. 5).

Pathophysiology

Turner’s syndrome is a condition that results from the absence of one female sex chromosome. It is characterised by infantile development of the genitalia, absence of breasts, short stature and a webbed neck. There may be associated congenital cardiac lesions.

Medical management

Chromosomal studies confirm the diagnosis. Early diagnosis is important and investigations can usually be initiated before puberty, suspicion being aroused by the short stature of the child. Treatment, such as ethinyl oestradiol 0.01 mg twice daily, in 3-week cycles, given for several months, then norethisterone added for the last 10 days of each cycle, can be used to stimulate development of the breasts and uterus. Menstruation may occur with this treatment.

Pituitary disorders

Disorders of the pituitary gland may result in the secretion of abnormal levels of hormones which affect the sensitive feedback mechanism ultimately affecting hormones of the menstrual cycle (see Ch. 5).

Emotional stress

Emotional disturbance is likely to affect menstrual function through the hypothalamic–pituitary axis. Emotional distress caused by some traumatic event may contribute to amenorrhoea.

Medical management

Discussion with a health professional will help the patient understand and be reassured about the effects of stress on menstruation. Physical and mental relaxation will help her deal with the stress and will promote a spontaneous return of menstruation.

Eating disorders

Eating disorders such as anorexia nervosa can affect the menstrual cycle.

Pathophysiology

Anorexia nervosa is associated with distortion of body image which results in disordered eating behaviour that includes dieting and extreme exercise routines and misuse of laxatives. There is extreme weight loss and dislike for foods, particularly carbohydrates. There is failure in hypothalamic stimulation of LH release and amenorrhoea occurs.

Medical management

Girls and women with anorexia nervosa are usually reluctant to accept they have a problem or to seek help. Their weight loss may be being investigated or they may present to their GP with another problem but when a diagnosis is made, care is usually maintained by mental health services. Positive physical and psychological changes can promote a return to menstruation.

Severe systemic illness

Pathophysiology

The stress of severe illness may induce ineffective functioning in multiple body organs and may temporarily suppress menstrual function. Stress, as experienced by prisoners of war or refugees, associated with malnutrition, minimal protein and vitamin intake, leads to amenorrhoea.

Medical management

When amenorrhoea is secondary to general illness, the medical condition must be treated before the amenorrhoea can be relieved. The influences of emotional and physical stress are complex, and sometimes assisting the patient to relax and lower anxiety levels may promote menstruation before the general illness is fully relieved.

Nursing management and health promotion: amenorrhoea

The nursing care for a patient with amenorrhoea is commonly undertaken in the community.

Planning care

The nurse should discuss with the patient reasons for amenorrhoea and how these relate to the patient. The patient’s level of anxiety should be noted and the nurse may recommend simple relaxation techniques or suggest relaxation audiotapes.

If, following a medical assessment, puberty is deemed to be delayed, reassurance and counselling are part of nursing care. Nurses can encourage optimism, provide general information about diet, exercise and lifestyle, and offer support, but in some cases skilled counselling may also be of value.

Evaluating care

The patient’s long-term goal of ‘return of menstruation’ may not be achievable within the early weeks of care and expectations should be realistic. This may include an evaluation of the level of the patient’s anxiety. The patient should be asked to report menstruation. Achievement of such a long-term goal may occur as a result of medical treatment, particularly if hormonal or anxiolytic drugs have been prescribed.

Dysmenorrhoea

Dysmenorrhoea is pain associated with menstruation. Many women experience minor discomfort, but dysmenorrhoea is more disabling. Before the start of bleeding, the breasts may feel larger and ache; women may also experience abdominal distension and bloating, constipation and feeling generally unwell. The symptoms may persist for 1–2 days and be relieved or replaced by backache, urinary frequency and loose stools once menstruation occurs.

For some women, the first hours or the first day are the most painful. Dragging sensations from the umbilical area down to the groins and thighs may be experienced, or the pain may be severe, colicky or spasmodic in nature across the abdomen and back. The pain may be so distracting as to interfere with the woman’s usual daily activities: 45–95% of menstruating women can be affected (Proctor & Farquhar 2006). Absenteeism from work and school is common due to symptoms of dysmenorrhea.

Two types of dysmenorrhoea are described:

• primary dysmenorrhoea (spasmodic) is due to physiological processes of menstruation, with muscle contraction

• secondary dysmenorrhoea (congestive) is associated with organic pelvic disease.

Primary dysmenorrhoea

Primary dysmenorrhoea is seen in young women in their late teens and early 20s. At first they may have anovulatory pain-free menstruation. Later, when ovulation becomes established, they experience pain 24 h before the flow begins. The pain is severe and colicky over the lower abdomen, often radiating to the thighs and back, and lasts for at least 12 h. Nausea, fainting and diarrhoea may accompany the acute phase and the girl looks tense, pale and drawn.

Pathophysiology

Dysmenorrhoea is associated with an increased production of endometrial prostaglandins, resulting in intense uterine contractions. Uterine arterioles can go into spasm and the resulting muscle ischaemia produces uterine pain.

Misunderstandings about the physical changes of menstruation and the nature of dysmenorrhoea may underlie ineffective management. Education about the nature of dysmenorrhoea and its effective management should therefore be addressed with young girls and their parents as appropriate (Box 7.1).

Rarely, dysmenorrhoea may be due to an obstruction to the flow of blood as a result of a clot being lodged in the cervix. Other possible causes include pelvic inflammatory disease (PID), endometriosis (ectopic endometrium present in the muscle wall, ovaries or elsewhere in the pelvic cavity) and congenital abnormalities.

Medical management

Detailed interviews may be carried out with the girl and her mother. In this way, shared and differing attitudes to the subject can be identified and problems defined. Vaginal examination may be carried out.

Efforts are made to educate the girl and her mother, as necessary, about normal menstrual function. A period of rest and the application of warmth to the abdomen or back may be helpful. Dysmenorrhoea should not be used as an excuse for avoiding school or work. Regular exercise, the avoidance of constipation and the prevention of anxiety are emphasised. Exercise encourages the release of endogenous endorphins which have natural analgesic properties. A series of exercises to stretch the ligaments that support the uterus in the pelvis may relieve menstrual pain. Attention should be paid to maintaining good posture.

Treatment

Treatment for dysmenorrhoea aims to relieve pain or symptoms either by affecting the physiological mechanisms behind menstrual pain (such as prostaglandin production) or by relieving symptoms. Treatments using simple analgesics such as paracetamol, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs) work by inhibiting prostaglandin production. An oral contraceptive may be indicated as these inhibit ovulation. A levonorgestrel releasing intrauterine system may also be of use. Slow release of levonorgestrel into the uterine cavity prevents thickening of the endometrium. Women may experience amenorrhoea with resultant reduction in dysmenorrhoea. The levonorgestrel releasing intrauterine system has also been shown to be effective in reducing dysmenorrhoea in women with endometriosis after one year (Vercellini et al 2003).

In severe cases, hysteroscopy (endoscopic examination of the uterine cavity) may be necessary to exclude uterine pathology. A laparoscopy may be required to exclude endometriosis. A pregnancy and vaginal delivery may improve or cure primary dysmenorrhoea.

Nursing management and health promotion: primary dysmenorrhoea

Assessment

An assessment should be made of the patient’s general health. The patient’s description of the nature of her painful periods should be recorded along with any observations about her physical and emotional symptoms on particular days of the cycle. Any medication used for pain relief or contraception, and its effectiveness, should be noted. Dietary habits and exercise activities are also relevant. Sensitive questioning of the patient will reveal any anxieties or stressors which may be contributing to symptoms.

Planning care

Care should be developed with the patient. Helping the girl/woman recognise signs of impending menstruation will allow her to take analgesics in time to prevent pain. A holistic approach to strategies to relieve pain should be discussed. Useful information includes:

• a simple explanation of how hormones function in the menstrual cycle and the effects of excessive prostaglandins

• discussion of the beneficial effects of a diet adequate in fibre, vitamins and polyunsaturated fats, and low in salt

• discussion of the patient’s present level of physical exercise and the benefits of exercise and good posture in stimulating organs and the release of pain-relieving endorphins (see Ch. 19)

• teaching simple relaxation exercises with referral to massage and local heat application

• discussion about drugs that inhibit prostaglandin secretion.

Evaluating care

A pain verbal rating scale could be used by the patient (see Ch. 19). If optimal pain relief is not achieved it may be necessary to amend analgesic regimens. Relaxation exercises should be used while the effects of analgesics are awaited. The achievement of the patient’s goals will be her first step in a change of lifestyle. Further support and encouragement may be given by her mother, friend, partner, a school or practice nurse or the GP.

Secondary dysmenorrhoea

Secondary dysmenorrhoea is experienced in later menstrual life by women in their mid-20s after years of painless menstruation.

Pathophysiology

Women usually complain of a dragging pain in the lower abdomen, pelvic area and breasts, accompanied by headache. The pain occurs some days before the menstrual flow and may continue throughout bleeding.

The condition is usually associated with pelvic pathology, although anxiety or depression can be an aggravating factor:

• Adenomyosis (infiltration of the myometrium by endometrial cells) – increased tension in the uterine muscle, as blood accumulates in the cystic spaces.

• Fixed retroversion of the uterus can cause severe pain, especially if associated with a low-grade pelvic infection.

• Partial stenosis of the cervix, following cautery or surgery.

• Endometriosis interferes with normal rhythmic uterine contractions.

• Pelvic congestion, due to increased blood supply to the uterus, and menorrhagia (see below).

• Pelvic inflammation, particularly salpingitis, might contribute to pain.

• Fibromyomata (‘fibroids’) and polyps interfere with normal rhythmic uterine contractions and cause muscular spasms as the uterus attempts to empty itself of the abnormal tissue.

Medical management

History and examination

A detailed history of the problem is recorded and a full physical examination including vaginal examination is undertaken to assess underlying causes. An accurate history of the pain is important, noting the age of onset, and the site, radiation, duration, character and time of onset in the menstrual cycle. The doctor seeks information about any related symptoms, possible abnormal uterine bleeding, pain on sexual intercourse (dyspareunia), pruritus and premenstrual tension.

Treatment

Investigations may involve hysteroscopy and endometrial biopsy. A laparoscopy may be performed if endometriosis is suspected. The presence of fibroids or polyps will be treated appropriately (see pp. 208–210). Pelvic inflammation can be treated by antibiotics. An analgesic drug can be prescribed that is suitable for inhibiting prostaglandin synthesis, e.g. mefenamic acid.

Nursing management and health promotion: secondary dysmenorrhoea

On assessment, pain will be identified as a problem. Goals and interventions will be similar to those described for primary dysmenorrhoea, particularly encouraging personal health messages. Additional problems will be identified and appropriate nursing interventions planned depending on the specific underlying pathology and the treatment interventions recommended.

Pre- and postoperative care planning will be needed if surgical procedures are planned (see Ch. 26). At the time of discharge the patient’s future prospects for an improved pattern of menstrual cycles should be better.

Abnormal uterine bleeding

Abnormal uterine bleeding is described according to the rhythm or pattern of blood loss:

• menorrhagia – heavy or profuse menstrual bleeding; bleeding occurs at normal intervals but is increased in amount or duration

• polymenorrhea – menstruation occurring with a frequency of less than 21 days

• polymenorrhagia – periods that are both heavy and frequent

• metrorrhagia – irregular or unusual uterine bleeding between periods

• dysfunctional uterine bleeding – abnormal uterine bleeding for which no organic cause is identified.

Abnormal uterine bleeding with the passing of blood clots is significant. The bleeding is greater than normal if the usual anti-clotting agents released by the endometrium are unable to control the volume or rate of blood loss.

Menorrhagia

Menorrhagia may be ovarian or uterine in origin.

Pathophysiology

Ovarian

There is hormonal imbalance (of oestrogen and progesterone secretion) usually due to the oversecretion of gonadotrophins. Emotional stress may contribute to this oversecretion.

Ovarian lesions are of two types:

• Polycystic growths – may disturb the normal production of ovarian hormones and excessive endometrial growth occurs.

• Immature follicles – may fail to result in ovulation. The corpus luteum fails to form, so progesterone cannot be produced. Oestrogen levels continue to rise and there is a proliferation of the endometrium.

Uterine

Lesions include:

• Fibroids – increase the endometrial surface area, thereby increasing bleeding. Fibroids may prolong the flow by restricting or disturbing contractions.

• Polyps – increase endometrial surface area.

• Adenomyosis – interferes with muscle contractions.

• Multiparity – reduced tone in the uterine muscle fibres caused by replacement by fibrous tissue will interfere with normal contractions.

• Developmental anomalies, e.g. a bicornuate, septate or duplicated uterus – may impede contractions.

• Endometriosis – is accompanied by increased blood supply to the uterus.

• Tumour formation – increases blood supply and bleeding.

• Intrauterine contraceptive devices – cause endometrial irritation. Excessive bleeding may be problematic during the first 3 months after insertion.

• Tubal ligation – involves some alteration in the course of blood vessels that increases uterine blood supply.

Medical management

Medical examination will try to establish whether bleeding is a problem of quantity or rhythm, or both. Pelvic examination may reveal tenderness, masses or irregularities. If nopelvic abnormality is found, then a provisional diagnosis of dysfunctional uterine bleeding is made.

Investigations

A full blood count will identify anaemia. Other endocrine imbalances may be important so thyroid function tests may also be done. An USS will help identify the presence of fibroids or masses. Hysteroscopy and endometrial biopsy may also be undertaken based on results of examination and USS.

Treatment

will depend on the amount of blood lost. Any anaemia identified should be corrected as appropriate. Mefenamic acid 500 mg or tranexamic acid 1 g, three times daily on the first day of the period and on other days with a heavy flow is often helpful, for a period of 3 months, followed by review.

Hormone therapy may be given. Progesterone may be prescribed to balance oestrogen secretion and reduce excessive endometrial growth. This may be in the form of the levonorgestrel releasing intrauterine system described under treatment of dysmenorrhoea. One of the combined contraceptive pills may be given to suppress hormone production. Progestogen administration will modify flow for patients with heavy but regular cycles.

Endometrial ablation is another treatment option for menorrhagia and is one of several minimally invasive procedures developed over recent years. It is undertaken as a day case procedure and is increasingly done as an outpatient procedure (Clark & Gupta 2005). This involves destroying the endometrium, preventing its cyclical regeneration. For many women the associated physical, social and psychological implications make it preferable to more extensive surgery such as hysterectomy. Different techniques have developed but they are based on the same principle which involves the introduction of instruments to destroy the endometrium using heat via a hysteroscope. These include:

• Balloon endometrial ablation – a special catheter is introduced via the cervix into the endometrial cavity. Water distends the catheter balloon so that it comes into direct contact with the endometrial lining. The water is then superheated to 87°C and left in situ for 8 minutes. The heat produced effectively destroys the endometrium.

• Electrical energy – a newer technique involves a similar procedure but uses a triangular mesh device which is introduced to the uterine cavity and expands to conform to the endometrial lining. Electrical energy is then delivered to destroy the endometrium as above, but only takes 90 seconds instead of 8 minutes.

• Freezing.

• Laser.

Following the procedure slight vaginal bleeding can be expected for a few days. Menstruation will become lighter or may cease, but dysmenorrhoea and premenstrual symptoms may continue. This procedure may require to be repeated at a later stage or a hysterectomy may eventually be necessary.

When a hysterectomy is deemed necessary it may be possible to undertake this without major surgery by means of laparoscopic surgery. This requires insertion of a number of small trocars through the abdominal wall, providing entry sites for instruments. The viewing laparoscope is inserted below the umbilicus, two other insertion sites will be positioned just above the pubic hair line and accessory insertion sites will be used for electrosurgical techniques, a stapling device or to insert sutures via the abdominal cavity. The woman can be discharged from hospital within 2 days.

If large fibroids or endometriosis exist, an abdominal hysterectomy is required. Alternatively, in the case of fibroids, a myomectomy may be appropriate, particularly if the woman wants to retain her uterus. Here the fibroids are shelled out of the myometrium.