REDUCED MENSTRUAL FLOW: CLINICAL PRESENTATION AND DIFFERENTIAL DIAGNOSES

CONTENT

-HISTORY

-PHYSICAL EXAMINATION

-DIFFERENTIAL DIAGNOSES

 

HISTORY

Immediately after delivery, a history of retained placenta followed by manual removal of the placenta and or curettage of the endometrium or inner lining of the womb, is often associated with Asherman syndrome. Not unusual, a co existing infection of the endometrial lining of the womb i.e. endometritis, may complicate the whole process worsening the damage to the endometrium. Occasionally, Asherman syndrome may occur after a cesarean delivery. Characteristically, it presents as the failure to resume menstruation or as the passage of a very scanty menstrual flow few months to years after delivery.

Similarly, uterine synechiae which essentially is Asherman syndrome occcuring in any other context other than during child birth, is common following endometrial injury in women with repeated D and Cs, D and Cs complicated with infection and endometrial injury during uterine surgeries such as myomectomy. Sunction evacuation of retained products of conception in women with incomplete abortion or women undergoing medical TOP, is a less common cause of uterine synechiae, hence it has become favoured over D and C, for the evacuation of retained products of conception.

Cervical stenosis, refers to the partial or total occlusion of the cervical canal due to cervical injury during surgical procedures on the cervix, such as D and C, cone biopsy or repair of cervical laceration resulting in healing by scarring and obstruction of the cervical canal. Commonly presenting as reduced, scanty or absent menstrual cycles, the occurence of cyclical lower abdominal pain associated with absent or scanty menstrual bleeding that may occur in some cases of cervical stenosis is known as cryptomenorrhea. Haematometra is a term used to describe trapping of blood in the uterus above the cervix due to complete cervical stenosis.

Similarly, a history of Female genital mutilation (FGM) or inadvertent insertion into the vagina of corrosive agents for social reasons or unorthordox treatment of various ailments is occasionally associated with scaring and occlusion of the vagina wall secondary to damage and destruction of the inner lining of the vaginal wall resulting in what is termed an acquired gynaetresia. In some instances, it may be so bad that the whole cervix and the vagina anatomy may be destroyed, followed by obliteration of the whole vagina by strong scars that forms along the whole length of the vaginal and the cervical opening. The presentation thereafter is usually similar to that described above for cervical stenosis in which there is associated reduced, scanty or absent menses, with or without cyclical lower abdominal pain due to trapping of blood above the occlusion in the vagina and the uterus. The trapping of blood within the vagina is referred to as haematocolpos. Other common presentations include dysuria and dyspareunia both referring to painful urination and painful intercourse respectively.

Tuberculosis endometritis refers to a tuberculosis infection of the endometrium. It may present with reduced or absent menses associated with chronic night sweats, fever and lower abdominal pain. Thankfully this is very rare and probably exist in settings of severe poverty and areas with high density of tuberculosis infection.

Finally, secondary amenorrhea is a desired complication and a reason for performing endometrial ablation for women with heavy or excessive mentrual flow.

 

PHYSICAL EXAMINATION

Although, most causes of reduced or scanty mentrual flow can be identified from the history at presentation, examination of the vagina, may reveal obvious lesions on the external part of the vagina along with variable occlusion of the vagina wall cavity, suggestive of gynaetresia cause by either FGM or insertion of corrosive agents into the vagina. In complete gynatresia of the vagina, a bulging of the vaginal wall may be noticed below the occlusion suggestive of haematocolpos.

A speculum examination of the cervix, may revealed an occlusion of the cervical os or trauma to the cervix in cases of suspected cervical stenosis due to D and C and or cone biopsy.

 

DIFFERENTIAL DIAGNOSES

Prior to investigations as to the exact cause of reduced and scanty menses, it is important to exclude other medical conditions that may present with absent or abnormal menstrual bleeding such as anovuatory diorders among others. The key difference is that these disorders cause variable amount of bleeding which are essentially irreglar and may be scanty one moment but heavy the very next moment. They include:

1.  PCOS

2.  Hyperprolactinaemia

3.  Thyroid disorders

4.  Perimenopausal state

5.  Sheehan’s syndrome

6.  Pregnancy

 

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