REPRODUCTION SYSTEM

MODUL 3
“MENSTRUAL DISORDERS”
TUTOR :
dr. Farah Ekawati Mulyadi

Group 6 English Class

• Chelsa Putri Ningsih 11020160001 • Anastasia Nugraha 11020160056
• Sitti Rahmadani Z 11020160106 • Defina Budi 11020160036
• Muh. Agung Gunadi 11020160096 • Bambang Sukoco 11020160019
• Mutmainna 11020160076 • Pratiwi 11020160006
• Nurul Ismira K 11020160066 • Alvi Kamal Fikri 11020150043
Scenario
A woman, 35 years old, P3A0, comes to the clinic with chief complaints frequent
spotting outside the menstrual cycle and has menorrhagia in her period. Previous
menstrual history was normal and from the history it was also known that the patient
was an IUD acceptor since 2 months ago.
 Difficult Word :
Menstruation

• Menstruation is a physiological or normal state, which is the event of expulsion of

blood, mucus and the remnants of cells which originates from the uterine mucosa and
occurs relatively regularly starting from menarche until menopause, except during
pregnancy and lactation. Duration of bleeding menstruation varies, generally 4-6
days, but 2-9 days is still considered physiological.

P3A0

• P3A0: P (Partus = number of deliveries), A (Abortion = number of abortions), so that

P3A0 is a patient who has delivered 3 times and has never had an abortion.

• Barret kim e, Susan M B, Scoot B, Heddwen L B. 2009. Ganong’s Review of Medial Physiology
 Difficult Word :
Menoragia

• Menorrhagia is bleeding that occurs in the future large amounts of menstruation can
be accompanied by clots blood even accompanied by dysmenorrhea. While
according to Prawirohardjo (2011), menorrhagia is menstrual bleeding whose total
blood count exceeds 80 ml in one cycle, and duration of more than 7 days, the
frequency of dressing can be more from 2-5 times a day.

IUD

• IUD (Intra Uterine Device) is a modern contraceptive device has been designed in
such a way (both shape, size, material and time active contraceptive function), placed
in the uterine cavity as an attempt contraception, blocking fertilization, and
complicating eggs implement in the uterus.
• Sarwono P., 2011, ilmu kandungan. In: Prof.dr.Mochammad Anwar, MMedSc S, ed. 3rd ed.

• Hidayati, E. 2009. Biostatistika Untuk Kedokteran Dan Kesehatan Masyarakat. Jakarta: Penerbit Buku Kedokteran EGC.
Key Word :
• A woman, 35 years old, P3A0

• Chief complaints frequent spotting outside the menstrual cycle

• Has menorrhagia in her period

• The patient was an IUD acceptor since 2 months ago

Questions :
1. How is physiology of menstruation ?
2. What is etiology of menstrual disorders?
3. How is pathophysiology of menstrual disorders?
4. What is the classification of menstrual disorders?
5. How is relation between IUD and the symptoms based on the scenario?
6. How is type of contraception?
7. How are steps to diagnosis menstrual disorders?
8. What is the treatment of menstrual disorders?
9. What is Islamic perspective about the scenario?
 Physiology of menstruation

Normal Menstrual Cycle

Ovarium :
1. Pholiculogenesis
phase
2. Ovulation phase
3. Luteal phase
Endometrium :
1. Proliferation phase
2. Secretary phase
3. Menstruation phase
• Lauralee, Sherwood, fisiologi manusia. Ed 6. Jakarta: egc. 2011

• Guyton and hall. Fisiologi kedokteran. Ed 11. Jakarta : egc

Etiology of menstrual disorders

1. State of Pelvic Pathology

 Surface lesions in the genital tract
 Deep Lesions

2. Systemic medical illness

• Hemostatic disorders

• Thyroid disease, liver, kidne failure

• Pituitary hypothalamic disorder: adenoma, prolactionoma, etc

• Prawiharjo, Sarwono. 2017. Ilmu Kandungan. Jakarta: Bina Pustaka

 Pathophysiology of menstrual disorders
Menstruation

Normal blood Abnormal liver Endocrionological

Reproduktive
release and kidney system
diseases
function abnormalites

1. Changes in the
endometrial wal
2. Endometrial blood
vessel vasodilation

More blood
expenditure and
• Wiknjosastro, Hanifa. 2011. Midwifery Science. Jakarta: Bina Pustaka Foundation Sarwono Prawirohardjo
longer duration
• Kusuma, N. Relationship between methods and duration of use with subjective health complaints in acceptors. University of Airlangga. Surabaya. East Java.2016
 Classification of menstrual disorders
Polimenorea
Menstrual cycle
disorders Oligomenorea

Amenorea

Volume and duration Menoragia

Classification of
menstrual disorders of menstrual
disorders Hypomenorrhea

Primary
Other Dysmenorrhea
menstrual Dysmenorrhea
disorders Secondary
Dysmenorrhea
• http://eprints.undip.ac.id. Cycle of menstruation. 2018
 Relation between IUD and the symptoms based on
the scenario
• Menorrhagia

Increase
concentration
increased prevents more bleeding
IUD of
fibrinolytic blood occurs during
insertion plasminogen
activity clotting menstruation
activators in
endometrium

• Blood spotting between menstrual cycles

increased
mechanical proteolytic Blood spotting
the use of
irritation from (fibrinolytic) inter-
IUD
the uterus wall activity of the menstrual
endometrium
• Yetti and Martini. 2012. Family Planning Services. Yogyakarta: Rohima Press.

• Glaciers, A. a. (2005). Family Planning and Reproductive Health Ed. 4. Jakarta: EGC.
Type of contraception
Non hormonal :
1. Contraception Without Using Drugs or Tools :
• Coitus Interruptus
• Postcoital Douche
• Prolonged Lactation
• Rhythm Method

2. Simple Contraception For Men

• condom

3. Simple Contraception For Women

• Pessarium can be divided in to 2 Groups : diaphragm vaginal dan cervical cap.
Type of contraception
Hormonal Contraception Consist Of:
1. Contraceptive Pill, Consist Of :
• Combination Contraceptive Pill
• Sequential Pill
• Mini-pill (Continous Low-dose Progesterone Pill, atau Prostagen Only Pill)
• Postcoital Contraception (Morning After Pill)
• menorea Pascapil (Post Pill Amenorrhoea)

2. Injection Contraception (Depo Provera), consist of :

• Injections every 3 Months (Depo Provera)
• Injections every Months (Monthly Injectable)

3. Intra Uterine Device (IUD)

• Sarwono, Prawirohardjo. 2016. Ilmu Kandungan. Edisi 3. PT. Bina Pustaka Sarwono Prawirohardjo; Jakarta.
 Step to diagnosis menstrual disorders
PHYSICAL
EXAMINATION
ANAMNESIS
- General impression
- Patient identity - Vital sign examination SUPPORTING
- Chief complaint EXAMINATION
- Abdominal examination
- General disease history - Breast examination
- Obstetric history - Laboratory examination
- Genitalia externa
- Gynecologic history examination - PAP smear
- Menstruation history - Inspekulo examination - USG
- Contraception history - Vaginal toucher
- Family history examination
- Recto vaginal
examination

• Speroff L, Glass R H, Kase N G, 1993. Clinical Gynecologic Endocrinology and Infertility,5 th edition, William & Wilkins, Philadelphia. 401 – 454.

• Baziad A, Surjana E J, 1993. Amenorrhoea Examination and Treatment, first edition, KSERI, Jakarta, 35 – 56.
 Treatment of menstrual disorders
MENSTRUAL DISORDERS

HISTORY & PHYSICAL

EXAMINATION

DISORDERS OF PREGNANCY
YES NO
MANAGEMENT OF DISORDERS OF
PREGNANCY
IATROGENIC CAUSES
YES NO

STOP IATROGENIC CAUSES SYSTEMIC DISEASE

YES NO

MEDICAL PELVIC PATHOLOGY

YES NO
DYSFUNCTIONAL UTERINE
BLEEDING

TREATMENT OF ABNORMAL UTERINE BLEEDING

Treatment of abnormal uterine bleeding

Medical treatment for menorrhagia

• Combination of estrogen progestin. The procedure for treatment is appropriate for the
treatment of irregular bleeding
• Progestin. Given if there are contraindications to the use of estrogen.
• NSAIDs (nonsteroidal anti-inflammatory drugs)
• The intrauterine contraceptive (IUD) contains Levonorgestrel.

Non-hormonal Therapy
• Nonsteroidal Antiinflammatory Drugs (NSAIDs). Mefenamic acid is given at a dose of
250-500 mg 2-4 times a day. Ibuprofen is given at a dose of 600 - 1,200 mg per day.
• Antifibrinolysis. Tranexamic acid works to inhibit plasminogen reversibly and if given
during menstruation can reduce the amount of bleeding 40 - 5O%.

Treatment with Surgical Therapy

• Hysterectomy
 Treatment of abnormal uterine bleeding

Combination of estrogen progestin

The dosage starts with 2 x 1 tablet for 5-7 days and after the
Dilation and bleeding occurs, followed by 1 x 1 tablet for 3-5 cycles.
Acute and curettage
Heavy Estrogen
Bledding Medical Estrogen therapy can be given in 2 forms, intra-venous or oral.
management The dose is 1,25 mg or 17 β estradiol 2 mg every 6 hours for 24
hours.

Progestin
Progestin is given for 14 days then stops without medication for
14 days, repeated for 3 months.
Treatment of abnormal uterine bleeding

Combination of estrogen progestin. Give

combination dose 1 x 1 tablet
contraceptive a day, given cyclic for 3
months.

Irregular bleeding
Progestin. If there are contraindications to
the use of combination contraceptive
pills, pro-gestin can be given for
example: MPA 10 mg 1 x tablet per day.
Treatment was carried out for 14 days and
stopped for 14 days. Progestin treatment
is repeated for 3 months.
 Treatment of bleeding uterus dysfunction
Menstrual Regulations To Be Normal Back
• Regulating Menstruation After Cessation of Bleeding Depends on Two Things, namely
Age and Parity.

Adolescents

• Combination of estrogen progesterone (combination contraceptive pill)

• Cyclic progestin, for example MPA dose of 10 mg per day for 14 days, 14 days later
without medication. Both treatments are repeated for 3 months.

reproductive age

• If multiparous parity: give hormonal contraception as above

• If you have infertility and want to get pregnant: give an induction of omlation

Age of Perimenopause

• Give low-dose combination contraceptive pills or DMPA injections

•Anwar, Mochamad. 2011. Ilmu Kandungan. Edisi ke-3. Jakarta. PT Bina Pustaka Sarwono Prawirohardjo. 168-173.
• Side effects that may occur after an IUD installer are changes in the menstrual cycle

(common in the first 3 months and will decrease after 3 months), longer and more
menstrual periods, bleeding (spotting) between menstruation, menstruation more
painful, and feeling pain and spasms during 3 to 5 days after installation. Until now
the mechanism of the IUD has not been known with certainty, now the most opinion
is that the IUD in the uterine cavity causes an endometrial inflammatory reaction
accompanied by the designation of leukocytes which can destroy the blastocyst or
sperm.
 • If vaginal and irregular bleeding occurs, then confirm and confirm the presence of

pelvic infection and ectopic pregnancy. If there are no pathological abnormalities,

ongoing bleeding and severe bleeding, do counseling and monitoring. Give ibuprofen
(800 mg, 3 times a day for 1 week) to reduce bleeding and give iron tablets (1 tablet
daily for 1-3 months). The IUD allows to be released if the client wants. If the client
has used an IUD for more than 3 bulls and is known to suffer from anemia (Hb
<7gr%), it is advisable to remove the IUD and help choose another appropriate
method.

• Anggraini, Yetti, dkk. 2012. Pelayanan Keluarga Berencana. Yogyakarta: Rohima Press.
• BKKBN. 2011. Buku Panduan Praktis Pelayanan Kontrasepsi. Jakarta: PT. Bina Pustaka Sarwono Prawirohardjo.
• Prawirohardjo, Sarwono. 2010. Buku Acuan Pelayanan Kesehatan Maternal. Jakarta: Yayasan Bina Pustaka
• Prawirohardjo,Sarwono.2016.Ilmu Kebidanan.Jakarta : Pt.Bina Pustaka Sarwono Prawirohardjo
Islamic perspective
• Q.S. Al-Baqarah (2) : 222

• And they asked you (Muhammad) about menstruation. Say, "it is something dirty."

Therefore stay away from your wife during menstruation; and don't approach them
before they are holy. If they have been holy, mix them according to what Allah has
commanded you. Really, Allah likes people who repent and like people to purify
themselves.
Thank You