Abnormal Genital Bleeding and Secondary Amenorrhea

principles and practice Abnormal Genital Bleeding and Secondary Amenorrhea Common Gynecological Problems JoELLEN M. MURATA, RN, PHD Abnormal genital bleeding and secondary amenorrhea (cessation of menses) are common gynecologic complaints that can indicate serious physical problems. Abnormal genital bleeding is the most common reason for a gynecological office visit and a leading indication for dilatation of the cervix and curettage of the uterus. One of four women with abnormal genital bleeding may have serious physical problems. Although pregnancy is the most common cause of secondary amenorrhea, other conditions related to abnormal pregnancy, functional disorders, physiological changes, or pathology also must be considered. Procedures for evaluating abnormal genital bleeding and secondary amenorrhea are discussed. Information is provided to assist nurses in collecting and assessing data and planning interventions to promote the health of women with these common problems.

In the United States, where 90% of women marry and bear children, the normal menstrual cycle is welcomed as a fertility sign and the hallmark of sexual maturity. However, menses is also called The Curse, an epithet that reflects the chronicity and gravity of problems that may be associated with t h e menses. Because menstruation may generate a gamut of ambivalent emotions that can contribute to menstrual dysfunction, an evaluation of abnormal genital bleeding o r secondary amenorrhea would not be adequate without an exploration of the client’s

Accepted: May 1989

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attitude toward her menstrual cycle. ~

THE MENSTRUAL CYCLE The menstrual cycle is controlled by the hypothalamic-pituitary-ovarian (HPO) axis, which, in childhood, initiates the events that precede puberty or the development of secondary sexual characteristics. As the HPO axis matures, menstruation’s cyclic nature is established. Menstrual regularity is usually evident from oneand-one-half t o two years after menarche, although monthly cycles may not occur until up to four years later. Normal menstrual

bleeding lasts from three to eight days, with an average blood loss of from 25 to 100 ml. The interval between menses varies in the individual woman from 21 to 40 days, counted from t h e first day of bleeding to the first day of the next menstrual bleeding.’ Variations in a woman’s cycle length are most common in the extremes of menstrual life, surrounding the events of menarche and menopause. However, irregular cycles during the active childbearing years are more significant to the clinician and the client. Predictable physiological changes occur during the menstrual cycle. These events produce signs, symptoms, and measurable physiologic alter-

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formed from cholesterol derived from low-density lipoproteins (LDL). Estrogen ana progesterone are required for the maintenance of the endometrium.

Uterine Changes

MENSTRUAL

PROLIFERATIVE I SECRETORY

MI DCYCLE

MlCROSCOPlC VIEW

Under the influence of estrogen, produced during the ovarian cycle’s follicular phase, the endometrium proliferates and thickens. As estrogen stimulation continues, t h e cervical mucus develops a characteristic fern o r palm leaf pattern when the mucus is dried and viewed under a microscope. As estrogen levels rise and ovulation approaches, the cervical mucus develops the tenacious attributes of raw egg white and becomes capable of stretching six centimeters or more. This characteristic, called spinnbarkheit, is closely associated with ovulation. At o d a t i o n , the proliferative (estrogen) uterine phase is replaced by the secretory (progestational) phase. Progesterone causes the cervical mucus to lose the characteristics of ferning and spinnbarkheit.3 Also associated with progesterone stimulation and ovulation are a shift in the vagina’s pH level from acid (4-5 pH) to alkaline (7-8 pH) and an increase in the vaginal cells’ glycogen ~ o n t e n t . ~

Figure 1. Menstrual cycle changes.

Systemic Changes ations in body chemistry (Figure 1).

Ovarian Changes Ovarian events are divided into two phases: the follicular (preovulatory) and luteal (postovulatory) phases. With hypothalamic influence the pituitary secretes follicle stimulating hormone (FSH), which stimulates the ovarian follicle to produce the estrogen, estradiol, from ovarian-produced an-

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drogens. The pituitary also produces luteinizing hormone (LH), which initiates ovulation and also stimulates the production of androgens, which, in the normal female cycle, are converted to estrogen and prostaglandins, which aid follicle rupture.* In the normal ovulating female the conversion of androgens produces the main source of estrogen. As ovulation occurs, the empty follicle assumes the production of estrogen and progesterone; progesterone is

Bodily changes of a cyclic nature accompany menstruation. These premenstrual symptoms, called molimina, usually are associated with ovulation, especially if the symptoms consist of breast tenderness and menstrual cramping. Molimina are ubiquitous and occur in t h e vast majority of women. More than 60% of women report physical symptoms, such as breast o r abdominal swelling, while more than 80%note irritability, tension, o r anxiety.’ 27

ABNORMAL GENITAL BLEEDING

Abnormal genital bleeding is the most common reason for a gynecological office visit and a leading indication for dilatation of the cervix and curettage of the uterus. For most women, the cause of abnormal bleeding is benign. Seventy-five percent of abnormal genital bleeding in adult women results from functional (nonorganic) causes; in adolescents functional causes reach 97%. However, the nurse clinician should bear in mind that 25%of abnormal genital bleeding results from organic causes, many of which represent life-threatening problems.' Because one of four women with abnormal genital bleeding may have a serious physical problem, organic causes of genital bleeding must be systematically excluded before a diagnosis of functional bleeding can be considered. Care should be exercised in this process. A significant portion of genital bleeding problems originally diagnosed as functional are later found to have organic causes. Pregnancy is the leading cause of uterine bleeding during a woman's childbearing years. Abnormal genital bleeding may result from an intrauterine pregnancy as well as disorders such as an ectopic pregnancy, a threatened or incomplete abortion, and postabortal trophoblastic neoplasms. Other organic problems that may cause abnormal genital bleeding include infection, neoplasm or lesions, hormone administration, trauma, blood dyscrasia, and extragenital bleeding. The nurse clinician should investigate all of these possibilities.

linguistic quirk, functional causes of uterine bleeding are termed dysfunctional uterine bleeding. Functional seems to refer to the lack of identifiable structural changes in the body that are associated with the abnormal bleeding. Of the 75% of abnormal uterine bleeding problems that can be classified a s dysfunctional, the majority of episodes occur at the extremes of menstrual life; 50% of dysfunctional uterine bleeding is found in women more than 45 years old and 20% in adolescents less than 20 years old.' Dysfunctional uterine bleeding in adolescence may portend grave problems. Some studies indicate that as many as 50% of adolescents continue dysfunctional uterine bleeding for more than four years. Of the adolescents who continue their abnormal bleeding patterns into adulthood, 70-80% will manifest fertility problems and increased incidences of endometrial cancer between the ages of 23 and 33.' Dysfunctional uterine bleeding may be related to either ovulatory or anovulatory cycles. Eighty percent of dysfunctional uterine bleeding cases are anovulatoryt h e duration and magnitude of bleeding correlate with the level and duration of the unopposed estrogen. The remaining 20% of dysfunctional uterine bleeding cases are ovulatory. The most common cause of ovulatory dysfunctional uterine bleeding is a corpus luteum d e f e ~ t ;however, ~ many problems classified a s ovulatory dysfunctional uterine bleeding actually result from organic causes. Most incorrect diagnoses related to abnormal genital bleeding are found in the ovulatory dysfunctional uterine bleeding category.

Dysfunctional Uterine Bleeding Evaluation

Most abnormal genital bleeding results from dysfunctional uterine bleeding. Through an inexplicable

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Uncontrolled uterine or intraabdominal hemorrhage may prove

1 Pregnancy is the most

I

common cause of abnormal genital bleeding and Isecondary amenorrhea.

fatal in less than 20 minutes. The nurse's initial assessment of the bleeding woman should focus on the quantity of blood loss and the potential for ectopic pregnancy. Heavy bleeding may require immediate hospitalization. The nurse should immediately record and monitor the woman's blood pressure. The woman at risk for pregnancy who presents the classic triad of unilateral abdominal pain, irregular menses, and vaginal bieeding should receive an immediate pelvic examination to exclude the possibility of an adnexal mass suggestive of ectopic pregnancy. Additional confirmatory examinations, such a s a blood pregnancy test and ultrasound, may be required on an emergency basis. A woman with a suspected ectopic pregnancy should arrive at a referral location capable of emergency pelvic surgery less than 20 minutes after the diagnosis is made. Nurses should develop appropriate referral and transportation resources before an emergency occurs. The time required to arrange a referral and transportation network may prove fatal to the woman. After a life-threatening emergency has been excluded, a thorough history and physical examination will differentiate organic causes of genital bleeding from ovulatory and anovulatory dysfunctional uterine bleeding.' Medical History A careful history of the present illness is critical to the diagnosis of abnormal genital bleeding. When eliciting the onset, course, and chronology of the abnormal

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bleeding, the nurse should note the client’s age of menarche. Late menarche suggests polycystic ovary disease (PCOD), also referred to as Stein-Leventhal syndrome, as a cause of the bleeding. The association of the onset of menstrual problems and interpersonal stresses, such as family problems, work difficulties, or sexual couple dysfunction, should be noted. The symptoms’ onset also may be associated with unusual weight gain o r loss, which may alter menstrual function.6 Bleeding with sexual relations is an important sign that may indicate an infection or a structural abnormality, such a s a polyp o r lesion. Trauma t o t h e genital organs should be carefully queried; rape and sexual violence frequently are the cause of bleeding. However, shame and denial, which interfere with disclosure of the event to the clinician, are common aftermaths of abuse. All genital bleeding in a premenarchal child should be viewed a s sexual abuse until proven otherwise. Menstrual flow characteristics provide important diagnostic information. Short cycles o r premenstrual spotting indicate low progesterone levels. Heavy, irregular, painless bleeding is associated with anovulatory cycles, which most often occur early or late in the menstrual years. Regular cycles with altered menstrual flow are not uncommon in early pregnancy. The date of the last menstrual period and the date of the last normal menstrual period should be recorded. These two dates may not coincide if pregnancy occurred after the last normal period. The presence of premenstrual symptoms or molimina diff erentiates the ovulatory from the anovulatory cycle. If progesterone is absent, breast tenderness and bloating d o not occur. Mittelschmerz and dysmenorrhea also

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a r e absent in t h e anovulatory cycle. Progesterone alters t h e vaginal discharge. Some observant women may note that the tenacious, thick mucus associated with the first weeks of the cycle does not change to a thin, watery consistency because of the progesterone absence in the anovulatory cycle.’ Other changes associated with the vaginal discharge-foul odor, increased quantity, irritation, dyspareunia, or itching-are symptoms associated with infection rather than progesterone absence.

Uncontrolled uterine or intra-abdominal hemorrhage may prove fatal in less than 20 minutes.

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When eliciting past medical history, the nurse should note the client’s hormone exposure. The woman born between 1940 and 1975 should be asked about in utero exposure to diethylstilbestroL4 The clinician may need to interview the client’s mother to obtain reliable information. A woman taking birth control pills may note breakthrough bleeding. If contraceptive education has been incomplete, t h e woman may not associate the abnormal bleeding with birth control pill use. Similarly, estrogen replacement therapy in the perimenopausal years may cause breakthrough bleeding. Endometrial cancer must be considered in the diagnosis of any abnormal vaginal bleeding of the perimenopausal years, particularly if t h e woman is receiving estrogen treatment. The clinician must obtain a client’s history of chronic disease and medication use t o identify drug-induced menstrual abnor-

mality (Table 1). A family history of delayed menarche, infertility, or heavy irregular menses may raise the possibility of polycystic ovary disease in female relatives, while a family history of blood dyscrasias may indicate a bleeding disorder in the woman. Health-care practitioners estimate that 19% of adolescents with heavy, regular, painless periods have a bleeding d i a t h e ~ i s .A~ family history of cancer or fibroid tumors could indicate a potential problem. An occasional client may fail to consider that bleeding noted on the underwear o r in the toilet originated from nonvaginal sources. The nurse should discuss the possibility of bleeding occurring from nonvaginal sources, such as hemorrhoids or the urinary tract. An obstetrical history is an important diagnostic tool. Repeated spontaneous abortions may indicate a luteal phase defect, while a history of infertility is most often associated with polycystic ovary disease. Intrapartum or postpartum difficulties may alert the clinician t o Sheehan’s syndrome, a rare form of pituitary necrosis secondary to hemorrhage. Certain symptoms related to the endocrine review of systems are important. Hirsutism may indicate polycystic ovary disease or adrenal problems. Symptoms of thyroid dysfunction and galactorrhea a r e frequently associated with menstrual cycle alterations.’ Pregnancy symptoms, such as nausea, vomiting, and urinary frequency, may be attributed to other causes if the pregnancy is unplanned.

Physical Examination If the abnormal genital bleeding is prolonged or severe, or a complete examination has not been recently performed, a total physical assessment is needed. All physical evaluations should cover the entire gyn area, which extends 29

Table 1. Common Drugs That May Alter Menstrual Bleeding Generic Name

Trade Name ~

*Amphetamines Anticoagulants 'Benzodiazepines Diazepam, Oxazepam Benzomide Derivatives 'Butyrophenones Cannabis Chloriazeponide 'Cimetidine Ethyl alcohol 'Isoniazid 'Methyldopa Monamine Oxidase Inhibitors 'Opiates 'Phenothiazines Rauwolfia Prostaglandin Inhibitors 'Reserpine 'Spironolactone Steroids Gonadal "Estrogens 'Progesterones *Testosterone Thyroid Hormones 'Thioxanthenes 'Tricyclic Antidepressants

*Desoxyn, Obetrol Coumadin, Heparin 'Valium, Serax Pronestyl, Matulane 'Haldol, lnapsine Marijuana Librium *Tagamet Whiskey, wine, beer 'INH "Aldomet Eutonyl, Nardil "Morphine, Heroin, Methadone 'Compazine, Thorazine, Phenergan Raudixin Motrin, lndocin 'Serpasil 'Aldactone

'Premarin, oral contraceptives 'Provera, oral contraceptives *Android Synthroid, Cytomel 'Navane "Elavil

May also produce galactorrhea.

from the chin to the pelvis. During the gyn examination, the thyroid is palpated for enlargement or nodules that may indicate dysfunction. The breasts are palpated for masses and galactorrhea. The abdomen is examined for masses and organomegaly, particularly of the uterus. The skin is assessed for evidence of atrophy or clotting disorders, such as bruises or petechiae. The estrogen level is assessed by observing the secondary sexual characteristics. Conducting a pelvic examination on a client is extremely important in evaluating abnormal genital bleeding. The client must be relaxed while the pelvic examination is conducted. Before examining an adolescent, the clinician should explain the examination and educate the adolescent in relaxation techniques. The clinician may need to use these same procedures for an adult woman who is 30

anxious about the examination or about abnormal bleeding implications. To allay anxiety, the nurse should review with the client the examination procedures in detail using anatomic charts and models. The nurse should offer the client the opportunity to handle the speculum and examination equipment, and the client should be assured that she will be allowed to end the examination if discomfort becomes intolerable. This reassurance often will gain the woman's cooperation and relaxation by giving her control of an anxiety-producing experience. To assess accurately the possibility of bleeding from sites other than the cervix, the clinician must view the external genitalia and vagina. The external areas should be cleansed and dried so that bleeding from a site can be observed. The clinician might simply pro-

vide the woman with the materials to wash her genitalia and perineal areas as she voids before the examination. The external genitalia, urethra, and rectal areas can then be inspected for bleeding, redness, hemorrhoids, or lesions. If no bleeding site is evident, the speculum is introduced and blood removed from the vagina. If the bleeding is heavy, a sponge forceps and a large supply of gauze may be needed. The clinician must identify the exact source of bleeding. A quick method is to locate and swab the cervix free of blood and observe whether bleeding recurs from the 0s. If the 0s or the cervix is not the source of bleeding, the vagina must be cleansed and inspected for bleeding sites. Occasionally an excoriated lesion, such as a venereal wart, can cause extensive bright genital bleeding. During the examination the cervix condition is observed. Abortion evidence may be present in the form of conceptus parts or 0 s dilatation. Vaginal lesions, cervical polyps, or friability may be found if a history of postcoital bleeding has been obtained. During the bimanual examination, the clinician palpates the vagina and cervix for lesions, which, if found, should be inspected for bleeding. The nurse also palpates the uterus and ovaries for masses, tenderness, and enlargement. Cervical motion tenderness or the chandelier sign is of great diagnostic importance in conditions that cause adnexal inflammation, such as ectopic pregnancy or pelvic infection. The rectal examination may reveal hemorrhoids. Suprapubic and urethral tenderness are evident in lower urinary tract infections. Laboratory Data

Several common laboratory tests are helpful in diagnosing ab-

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normal genital bleeding. If bleeding is light, assessing the cervical mucus for ferning to determine estrogen levels may be possible. Large amounts of blood interfere with the visualization of the fern pattern. The Papanicolaou test also will indicate estrogen levels. Cytology samples may be taken after excess blood has been wiped away so that cervical and vaginal cells are not obscured by red cells. Pregnancy tests are useful. However, they may yield negative, but misleading, results. During ectopic pregnancy and spontaneous abortion, the human chorionic gonadotrophin (HCG) levels may be too low to detect.8 A hematocrit or complete blood count will determine anemia secondary to blood loss. If the clinician suspects blood dyscrasia, a coagulation evaluation, which includes a platelet count, prothrombin time, partial thromboplastin time, and bleeding time, may be requested. If symptoms or signs of thyroid abnormality exist, thyroid studies should be obtained. If cervical motion tenderness is discovered, cultures for chlamydia, gonorrhea, and other common pathogens originating in the bowel are indicated. If vaginal irritation or discharge is evident, a mixture of the discharge with saline may be viewed under the microscope to detect monilia, trichomonas, bacteria, or clue cells. Assessment When forming a diagnosis, the clinician should be particularly suspicious of an intrauterine o r abnormal pregnancy. Symptoms of nausea and breast tenderness, signs of an enlarged uterus, and a soft, bluish cervix and vagina associated with a normal adnexal examination should alert the clinician to an intrauterine pregnancy. An abnormal pregnancy also may manifest the same signs and 191 JanuaryfFebruary 1990 JOCNN

symptoms. Bleeding, abdominal cramping, cervical dilatation, and the presence of conceptus parts may indicate a spontaneous abortion is impending or in progress. Unilateral adnexal tenderness, palpable adnexal mass, and cervical motion tenderness are important ectopic pregnancy indicators. These same signs may accompany pelvic infection; however, purulent cervical discharge usually occurs with pelvic infections. An enlarged uterus accompanied by regular, heavy menses may indicate fibroids. In the perimenopausal woman, abnormal uterine bleeding should be considered endometrial cancer until the clinician obtains a normal endometrial biopsy. Although useful for determining cervical pathology and estrogen levels, the pap test is inadequate for evaluating endometrial cells and cannot replace an endometrial biopsy. When diagnosing abnormal genital bleeding, the clinician must first exclude pregnancy, neoplasm, infection, trauma, hormone administration, and blood dyscrasia as causes. After organic causes have been ruled out, attention is focused on the type of dysfunctional uterine bleeding. Dysfunctional uterine bleeding that is associated with premenstrual symptoms, such as breast tenderness, dysmenorrhea, and bloating, is considered to be ovulatory dysfunctional uterine bleeding. The most common cause of ovulatory dysfunctional uterine bleeding is a corpus luteum dysfunction, which often is amenable to hormonal therapy. All women with ovulatory dysfunctional uterine bleeding should be referred to a gynecologist for a thorough evaluation and possible treatment of the underlying condition. The most common cause of anovulatory dysfunctional uterine bleeding is malfunction of the hypothalamic-pituitary-ovarian

axis. As the axis develops during the first two years of the menstrual cycle, anovulatory menses characterized by heavy, irregular, painless bleeding are common. Recurrence of the anovulatory dysfunctional uterine bleeding pattern is associated with menopause. During the intervening childbearing years, the most common causes of anovulatory dysfunctional uterine bleeding are stress and polycystic ovary d i ~ e a s eThe . ~ absence of hirsutism or infertility in a woman with anovulatory dysfunctional uterine bleeding suggests stress or nutritional causation. This diagnosis may be validated by the finding of normal LH levels. Polycystic ovary disease is associated with high LH levels.

Nursing Management Management of abnormal genital bleeding depends on the severity of the underlying pathology and bleeding episodes. The nurse practitioner may manage anovulatory dysfunctional uterine bleeding of the woman with moderate bleeding episodes in the early and late menstrual years and the occasional series of anovulatory cycles in the middle menstrual years. For these women, management by the nurse will involve health education, supportive counseling, regular monitoring of menstrual function, and assessment of iron levels in the blood. Iron replacement should be given as the need develops. The woman with frequent or heavy anovulatory dysfunctional uterine bleeding should be managed in consultation with a gynecologist for bleeding control. The longer the estrogen stimulation between anovulatory periods, the heavier may be the menstrual bleeding. To control heavy bleeding and effect regular endometrial shedding, cyclical hormone therapy in the form of birth control 31

pills or alternating estrogen and progesterone medications may be used. However, no estrogen regimen should be initiated until the possibility of pregnancy or estrogen dependent neoplasm of the endometrium, breasts, or ovaries has been ruled out.' Cyclical hormone regimes can be monitored by the nurse practitioner in consultation with a gynecologist.

All women with a history of anovulatory bleeding should be carefully instructed in the danger of intermenstrual bleeding as a sign of endometrial Icancer. Occasionally anovulatory bleeding occurs with such intensity that immediate treatment must be initiated to prevent serious blood loss and anemia. Any birth control pill taken several times a day for several days may be used to control a heavy menstrual flow. Regular cycling with the birth control pill or estrogen-progesterone compounds can then begin. On rare occasions the endometrium becomes depleted by heavy anovulatory bleeding and fails to respond to the low-dose estrogen-progesterone therapy of the birth control pill. Intravenous estrogen can be used to stimulate the endometrial growth before cyclical hormones are given.' In the perimenopausal woman, an endometrial biopsy or dilatation of the cervix and curettage of the uterus to exclude the possibility of endometrial cancer should be done, and a complete pelvic and breast examination should precede estrogen administration. Unopposed estrogen stimulation of the endometrium results in hyperplasia and, some authorities believe, the potential for cancer. For this reason long time periods between menses are undesirable. 32

Controlled endometrial shedding induced by progesterone withdrawal at regular intervals prevents hyperplasia. Withdrawal bleeding is dependent on an endometrium adequately primed with estrogen and the absence of pregnancy. Because of the possible teratogenic effects of progesterone, administration to achieve endometrial shedding should be accompanied by secure contraception. Progesterone as a single agent may be administered to women who have adequate estrogen levels and are not sexually active, are sterile, or reliably use barrier methods of birth control. Other women may be cycled on birth control pills or sequential estrogen-progesterone medications. All women with an anovulatory bleeding history should be carefully instructed in the danger of intermenstrual bleeding as a sign of endometrial cancer. This symptom should be promptly reported to the clinician. Hysterectomy is frequently recommended for the perimenopausal woman with bleeding that is difficult to control. Despite the frequency with which the surgery is performed, hysterectomy is not an innocuous procedure. Some reports indicate that more than 50% of hysterectomies are followed by infection." The nurse should bear in mind these statistics when counseling women with uterine bleeding problems. ~~

SECONDARY AMENORRHEA

Amenorrhea is a symptom underlying a disorder that may be considered to be either primary or secondary. Primary amenorrhea refers to the absence of menarche. The criteria for secondary amenorrhea includes the cessation of menses for more than 1) six months or three cycles, 2) three months after a term delivery in a

nonlactating mother, or 3) more than eight weeks after an induced abortion.' After age 40, normal menopause may be suspected as the cause of amenorrhea. Although arbitrary time lines are used as guides for correct diagnosis, the client may seek evaluation of her amenorrhea long before the diagnostic guidelines can be applied. Nevertheless, an evaluation of the concerned woman with amenorrhea should be conducted. Factors that commonly affect the menstrual cycle can be explored and, if indicated, supportive counseling offered. This approach may resolve the question of whether or not emotional stress is a potential cause of the amenorrhea. If an abnormality is detected, early treatment can be initiated. Pregnancy is the most common cause of secondary a m e n ~ r r h e a . ~ Before other causes of secondary amenorrhea can be considered, pregnancy or pregnancy complications, such a s ectopic pregnancy, missed o r incomplete abortions, or trophoblastic neoplasm, must be ruled out. Functional disorder of the HPO unit is another common cause of secondary amenorrhea. Physical and emotional stress, malnutrition, and obesity are included in this category. Postpill amenorrhea, secondary to inhibited gonadotrophic releasing hormone, also may have a hypothalamic origin. Certain physiologic causes of secondary amenorrhea may be overlooked by the hurried clinician. Lactation frequently passes unnoticed. Menopause produces secondary amenorrhea in 45% of women aged 45-49, in 65% of those aged 50-52, and in more than 70% of those aged 53.' Polycystic ovary disease ranks first among pathologic causes of secondary amenorrhea. Polycystic ovary disease is characterized by hirsutism, infertility, and irregu-

19:l JanuaryJFebruary1990 JOCNN

lar, heavy anovulatory menses, followed by amenorrhea. Only rarely does the disease produce primary amenorrhea.

I

Many medications used in managing common chronic diseases interfere with the menstrual cycle.

Secondary amenorrhea may be associated with galactorrhea. The most frequent cause of this symptom complex is stress, which produces high levels of prolactin, a pituitary hormone that stimulates milk production and suppresses menstruation. Secondary amenorrhea, with or without galactorrhea, may be the result of breast stimulation or drug therapy. Although secondary amenorrhea and galactorrhea usually result from stress, the symptom complex also may signal serious disease. About 25% of women with these symptoms are found t o have a pituitary tumor. To evaluate secondary amenorrhea, the nurse must obtain a detailed medical history from the patient. A physical examination is less helpful in determining the diagnosis.

Evaluation Medical History The nurse clinician should gather and record t h e client’s complete health history, especially in the event of long-standing secondary amenorrhea. Some areas of the client’s medical history are particularly important. A complete obstetric and menstrual history and a careful history of present illness, past medical problems, and personal and sexual habits are critical. When probing the onset of secondary amenorrhea, t h e nurse should differentiate gradual onset, which indicates a hormonal o r systemic disorder, from abrupt 19:l JanuaryIFebruary 1990 JOGNN

menstrual cessation, which may signal pregnancy o r functional disorder. Note any chronic illness. Many medications used in managing common chronic diseases interfere with the menstrual cycle (Table 1).1’~’2Deliveries, pelvic surgeries, infections, and radiation a r e important. Adhesions after pelvic infection or endometrial depletion after abortion may produce secondary amenorrhea. Serious postpartum hemorrhage may cause pituitary failure and subsequent amenorrhea. The nurse should question the woman about t h e existence of polycystic ovary disease o r infertility in female relatives. This information may provide clues of a genetic origin to the client’s problems. Sexual practices that involve unusual breast stimulation may cause elevations of prolactin levels and suppression of menstruation. Symptoms of androgen excess or estrogen deficiency should be noted. Masculinization resulting from androgen excess is manifested in its early stages by hirsutism and voice deepening, and later by frontal balding and clitoromegaly. Estrogen deficiency symptoms include hot flashes, decreased libido, breast and genital atrophy, and scant cervical and vaginal mucus. Symptoms such as headaches and visual defects may b e associated with a pituitary tumor. Only rarely are hypothyroidism symptoms associated with secondary amenorrhea. Psychological stressors in interpersonal o r work environments are common causes of menstrual dysfunction. Poor nutritional habits, bulimia in normal-weight women, o r unusual weight gains or losses may cause secondary amenorrhea.6 Inquiring about a client’s personal habits often provides important diagnostic information. Rigorous exercise regimens are

strongly associated with amenorrhea. The possibility of menstrual dysfunction induced by illicit drug use should be explored. When discussing this sensitive area, the nurse should describe the drugs that may alter menstrual function and query the woman about their use, rather than attempt to compile a complete drug-use history. Discretion should be used in recording confidential information that may place the woman or the clinician in a compromised legal position.

Physical Examination The clinician should perform a general physical examination and a pelvic examination. The client’s height, weight, and blood pressure should be compared with the norms. Although obesity may cause secondary amenorrhea, polycystic ovary disease produces obesity in 50% of afflicted women.13 Low weight may be evident in the anorexic or bulimic woman. Blood pressure may be elevated in adrenal problems or in essential hypertension, which is inadequately controlled by drugs that cause secondary amenorrhea. While performing the general survey, the clinician should observe the secondary sexual characteristics for evidence of estrogen stimulation. Late signs of masculinization o r virilization may indicate adrenal problems or a severe form of polycystic ovary disease, while hirsutism may indicate milder forms of this d i ~ e a s e . ~ Breast, genital, and skin atrophy may point to ovarian failure. The clinician should examine the thyroid for nodules or enlargement. If galactorrhea is found during breast assessment, a visual field examination may be performed in which the clinician attempts to identify a pituitary mass affecting the optic chiasm. However, this examination will detect

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only gross defects. CAT scan and polytomography are preferable if a pituitary tumor is suspected. The fact that a sexually mature woman has had many pelvic examinations does not ensure that she will relax and cooperate. Previous examinations may have been poorly conducted o r painful. Rarely does a woman like the pelvic examination: The clinician should explain to the patient that she must relax for the clinician to conduct a thorough examination. A patient’s dislike of the procedure and her resultant muscle tension can interfere with a thorough examination, and, subsequently, lethal abnormalities can be missed. If necessary, the clinician should instruct the patient in deep breathing and pelvic relaxation techniques. During the pelvic examination, pregnancy indicators, such a s uterine enlargement, softening of the lower portion of the uterus (Hegar’s sign), o r blueness and softening of t h e cervix (Chadwick’s sign), a r e sought. Scant cervical mucus and vaginal rugae and lubrication losses, which indicate estrogen deficiency, should be noted. The ovaries and adnexae should be carefully palpated for signs of enlargement, which is characteristic of polycystic ovary disease or tumors. Ovarian cancer seldom presents early symptoms; however, ovarian cancer rarely causes amenorrhea.

Laboratory Data Pregnancy testing is mandated in any sexually active woman. Some urine tests do not indicate pregnancy before four weeks o r 30 days after conception in a woman with a 28-day cycle. Other pregnancy tests, including those of the blood, show positive results about 10 days after conception. Although more costly, tests that give early indication of pregnancy may be 34

preferable because of the amenorrheic woman’s special concerns regarding childbearing. Because the amenorrheic woman may conceive during ovulation, which precedes the onset of menses,’*5a potentially teratogenic medication regimen should not be administered until the possibility of pregnancy is excluded and contraception is assured.

The treatment goal for the nonpregnant, amenorrheic woman with adequate estrogen levels is the return of regular menstruation.

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The assessment of the woman’s estrogen levels made during the physical examination can be confirmed with reports of estrogen stimulation of t h e vaginal cells noted in the routine pap test and with a cervical mucus evaluation. Cervical mucus ferning indicates adequate estrogen levels and rules out pregnancy. Progesterone, present during pregnancy, obliterates the cervical mucus’ tendency to form the fern at tern.^ If the two most common causes of secondary amenorrhea, pregnancy and hypothalamic-pituitary-ovarian axis dysfunction, have been ruled out because of androgenization or indications of thyroid, pelvic, o r pituitary disease, additional evaluation of FSH, LH, prolactin, and thyroid levels may be indicated.

Assessment Hormone-level evaluation in the woman with secondary amenorrhea may differentiate the various endocrine causes of amenorrhea. FSH levels are high in menopause and in other causes of ovarian failure. FSH levels are low in pituitary failure and possibly polycystic ovary disease. LH is high in poly-

cystic ovary disease and ovarian failure.4 Elevated serum prolactin levels require careful assessment. An estimated 15-40% of women with secondary amenorrhea have elevated serum prolactin. This incidence increases t o 79-97% in women with both secondary amenorrhea and galactorrhea. While serum prolactin levels are high in pituitary tumors, usually exceeding 300 ng/ml, stress-, drug-, or thyroid-induced prolactin levels rarely exceed 100 ng/ml.’*

Nursing Management After t h e cause of secondary amenorrhea has been established, the nurse may promote the woman’s health through counseling and educational activities specific to the problem. Women with secondary amenorrhea associated with androgenization; premature ovarian failure; or abnormal FSH, LH, o r thyroid hormone levels should be evaluated by a reproductive endocrinology specialist. Women with secondary amenorrhea associated with a normal physical examination, normal estrogen levels, and a normal o r pregnant pelvic examination may be offered education and supportive counseling in consultation with the appropriate medical generalist, An abnormal pregnancy must be immediately referred to an obstetrician. Nurses should not overlook the possibility of an ectopic pregnancy. The treatment goal for the nonpregnant, amenorrheic woman with adequate estrogen levels is t h e return of regular menstruation. A woman with prolonged secondary amenorrhea may develop diminished bone mass. Researchers are investigating the relationship of diminished bone mass in secondary amenorrhea to circulating levels of estrogen and

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the long-term development of 0steoporosis. However, the return of regular menstruation prevents both bone mass loss and endometrial hyperplasia o r cancer that may result from prolonged secondary amenorrhea. By obtaining a patient’s complete medical history, a skilled clinician can delineate the cause of hypothalamic-pituitary-ovarian axis dysfunction. Excessive stress at home or work frequently is discovered. The hurried mother who has small children and who works outside the home, or the college student with academic, job, and social obligations, may be greatly overworked. The nurse can provide supportive counseling and assistance with problem solving to these women. Severe family problems may require referral for specialized marriage or parent-child counseling. Providing an overweight patient with nutritional counseling during supportive visits often will prompt the patient to diet. The nurse may need to recommend that the patient join a weight-loss group. The anorexic o r bulimic woman requires psychiatric management of her eating disorder. Secondary amenorrhea associated with chronic diseases, such a s hypertension, diabetes mellitus, arthritis, mental illness, tuberculosis, and drug o r alcohol abuse, can be evaluated in the course of routine care, and medication regimens can be examined for menstrual effect. Consultation with a medical specialist may be necessary for women who are not in a stable phase of their diseases. The management of secondary amenorrhea resulting from hypothalamic-pituitary-ovarian axis dysfunction may involve the use of medications. To assess the integrity of the reproductive mechanisms and structures, some clinicians administer a progesterone challenge. In the woman with ade-

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quate estrogen levels, this test produces withdrawal bleeding within two weeks after the administration of progesterone.’ Because of the potential of progesterone to damage the fetus, the possibility of pregnancy must be excluded before the medication is given. The progesterone challenge test does not restore normal menstruation. Some authorities contend that a skillful clinician can determine t h e integrity of the menstrual mechanism more safely through careful physical and pelvic examinations, in conjunction with the pap and fern tests to assess estrogen levels. Secondary amenorrhea resulting from hypothalamic-pituitaryovarian axis dysfunction may persist despite counseling interventions. For some women fertility may not be an issue during amenorrhea. However, if pregnancy is desired, the nurse can refer the woman to a fertility specialist for ovulation induction. Clomiphene citrate frequently is used for this purpose. If adequate estrogen levels have been found and contraception is desired, cyclic bleeding may be induced by estrogen-progestero n e therapy. A low-dose birth control pill may be chosen for this purpose. The potential benefits of cyclical bleeding on t h e bone mass and endometrium should be weighted against the possibility of prolonged postpill amenorrhea. The nurse should frankly discuss the pros and cons of hormonal treatment with the woman. The nurse should inform the client that postpill amenorrhea has not been found to exert a strong effect on long-term fertility. The woman with persistent secondary amenorrhea, with or without long-term cyclic estrogenprogesterone therapy, should be followed up in the event that a serious covert cause of the secondary amenorrhea becomes evident.

The nurse can educate the woman about t h e need for continued heaith supervision. NURSING IMPLICATIONS

Pregnancy is the most common cause of abnormal genital bleeding and secondary amenorrhea. During the menstrual years some abnormalities, such a s uterine hemorrhage and ectopic pregnancy, may require immediate surgery to sustain life. The nurse may be the first health-care provider that the woman with abnormal genital bleeding or secondary amenorrhea encounters. A rapid and accurate assessment of the patient for the potential of a lifethreatening emergency is an important nursing activity. The nurse also should develop a referral and transportation network for emergency pelvic surgery before the need arises. The accurate diagnosis of pregnancy may depend on the nurse’s ability to maintain a nonjudgmental attitude and establish a rapport with the client that facilitates accurate history taking. Although nurses practice in many different roles with a variety of clients and co-workers, the core activities of nursing, which relate to patient advocacy, education, and supportive counseling, remain unchanged across settings. When gathering a patient’s history, the nurse should explore the woman’s attitude toward her menstrual cycle, use of medications and drugs, food intake, exercise patterns, and sources of psychological stress. This information may yield important diagnostic information and clues and indicate a patient’s need for further education and counseling. The nurse should advocate t h e patient’s right t o a sensitive, supportive physical examination, review examination procedures with the patient, and instruct her in relaxation techniques. The nurse must

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educate and prepare t h e woman for referral and diagnostic tests and interpret t h e plan of care. In caring for t h e woman with abnormal genital bleeding or secondary amenorrhea, nursing provides essential patient-oriented services.

REFERENCES 1. Pauerstein, C. (ed.). 1982. Cynecologic Disorders. New York Grune and Stratton. 2. Sonstegard, L. (ed.). 1982. Women's Health Ambulatory Care. New York: Gruen and Stratton. 3. Fogel, C., and N. Woods. 1981. Health Care of Women. St. Louis: C. V. Mosby. 4. Green, T. 1977. Gynecology Essentials of Practice. 3d ed. Boston: Little Brown & Co.

5. Willocks, J. 1982. Essentials of Obstetrics and Gynecology.2d ed. New York Churchill Livingstone. 6. Warren, M. 1983. Effects of undernutrition on reproductive function in humans. Endocr Rev. 4(4):36377. 7. Danforth, D., and J. Scott. 1986. Obstetrics and Gynecology. 5th ed. Philadelphia: J. B. Lippincott. 8. Bluestein, D. 1988. Monoclonal antibody pregnancy tests. Am Fam Physician. 38(1):197-204. 9. Tudiver, F. 1983. Dysfunctional uterine bleeding and prior life stress. J Fam Pract. 17(6):9991003. 10. Hemsell, D., R. Bawdon, P. Hemsell, B. Nobles, E. Johnson, and M. Heard. 1987. Single dose cephalosporin for prevention of major pelvic infection after vaginal hysterectomy. Am J Obstet Cynecol. 156:1201-5. 11. Neinstein, L. 1985. Menstrual dys-

function in pathophysiologic states. West J Med. 143(4):476-84. 12. Malo, J., and B. Bezdicek. 1986. Secondary amenorrhea. Postgrad Med. 79(3):86-100. 13. Hammond, M., L. Talbert, and T. Groff. 1986. Hyperandrogenism. Postgrad Med. 79(3):107-13.

Address for correspondence: JoEllen M. Murata, R N , PhD, University of Rochester, School of Nursing, 601 Elmwood Avenue, Rochester, NY 14642.

JoEllen M. Murata is a family nurse practitioner and an assistant professor in the School of Nursing at the University of Rochester in Rochester, New York. Dr. Murata is a member of the American Nurses Association, the American Public Health Association, and Sigma Theta Tau.

REFEREE REVIEWERS Lynette A. Ament, RN, MSN Debbie Fraser Askin, RNC, BN Louise A. Aurilio, RNC, MSN Paulette Avery. RN, MSN Susan Scheuring Barleben, RN, MSN, FNCC Leah Beardsley, RNC, MSN, CRNP Charles R. B. Beckmann, MD, MHPE, FACOC Pamela Butler Beeman, RN. PhD Abbe Bendell, BSN, MBA-HA Ann Boeke, RN, MS Linda Bond, RNC, PhD Mary Ann Braun, RN, MSN, ARNP Marie Annette Brown, RN, PhD, WHCNP Angeline Bushy, RN, PhD Rebekah Carey, RNC, MSN Judith Ann Carveth, RN, CNM, MSN Jimmie Cash, RN. MSN Janet M. Claypool, RNC, MN Judith M. Collinge, RNC, MSc(A), MBA John Collins, CNM, MSN Carris Keels Conner, RN, DSN Lynne H.Conrad, RNC, MSN Rachel L. Copper, RN, MSN Ann E. Edgil, RN, DSN Juanzetta S. Flowers, RN, DSN Margaret Comerford Freda, RN, EdD Barbara Horn Frentzen, RN, MSN

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Catherine Garner, RNC, MSN, MPA Janice Templeton Cay, RN, DSN Susan K. Goodale Celatko, RN, MA Susan Cennaro, RN, DSN Peggy Cordin, RNC, MS Linda A. Graf, RNC, CNM, MS Laurie P. Gunderson. RN. PhD Karen Ruth Hammond, RN, MSN Judith Harris, RNC, MN Anita L. Hartrnan, RN, MSN Maureen Heaman, RN, M N Pamela L. Jordan, RN, PhD Roberta Karlman, MD Virginia H. Kemp, RN, PhD Carole Kenner, RNC, DNS Kathryn Kerber, RN, MS Marcia Killien. RN, PhD Michelle S. Knolla, MD. FAACOG Dona J. Lethbridge. RN, PhD Judith A. Lewis, RNC, PhD Cheryl Pope Long, RN, MSN, EdD Denise R. Lucas, RN, MSN Debra L. Luegenbiehl, RN, PhD Lynn E. Lynam,RNC, MS Marlene C. Mackey. RN, PhD Susan D. Mattson, RNC, CTN, PhD Katharyn Antle May, RN, DNS Anne M. McCormick, RN, MS Kay McChee, RNC, MSN Nancy J. McKee, RN, DNS

Mary Ann Miller, RN, MSN Karen H. Morin, RN, DSN Laura Mueller, RNC, MSN Nancy O'Brien-Abel, RN, MN . Sandra J. Olanitori, RN, MS Ellen Olshansky, RNC, DNSc Karen M. Pangborn, RN, MS Ellen Tate Patterson, RN, DSN Karen Peddicord, RN, MS Nancy Peterson, RN, BSN Patricia Pollert, RNC Alicia Poslosky. RN, MSN Deborah Ann Raines, RNC, MSN Ginny Reed, RN, MSN, CNM Jacquelyn Reid, RN, BSN, MA, EdD Diana J. Reiser, RN. MAEd, MN Deidre Richards, RNC, MSN Jean M a , RN, MSN Lynn Clark Scott, RN, MN Pat Serio, RNC, BA Mary K. Shannahan, RN, PhD Phyllis W. Sharps, RN,..PhD Darlene Stewart, RNC, BSN, CNA Judith P. Stocks, RN, PhD Cecilia M. Tiller, RN, DSN Susan E. Trippet, RN, DSN Nan H. Troiano. RN, MSN Joyce Marilyn Vickers, CMM, NPC Loretta Walker, RN Ruth York, RN, PhD

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