Management of menstruation and menstrual problems among urban and rural secondary school girls

Introduction

Secondary school girls are in a period of growth and development known as adolescence. Adolescence is a period of transition from childhood to adulthood. It is a stage of human development that is characterized with so many physical, social, emotional and mental changes. There is appearance of secondary sexual characteristics, in girls menstruation is one of these major characteristics. The onset of menstruation represents a landmark event in pubertal development of the adolescent girl. Menstruation is a natural phenomenon that occurs from puberty throughout the reproductive life of every female. It is a periodic vaginal bleeding associated with shedding of uterine mucosa. Every mature woman menstruates on the average of three to five days monthly until menopause (Lawan, Yusuf & Musa 2010). Esimai and Esan (2010) assert that normal menstruation relies on action and interaction of hormones released from Hypothalamus – pituitary and ovaries and their effects on the endometrium. The normal menstrual pattern is associated with 3 to 7 days length of flow and amount of flow less or equal to 80ml. A woman’s period may not be the same every month and it may not be the same as that of other women. Periods could be light, moderate or heavy and the length of the period also varies. Menstruation is a normal process of the body and if proper knowledge is given regarding its onset, management and problems associated with it; then it can be handled like all other body functions. However, many girls in developing countries lack appropriate knowledge and sufficient information regarding menstruation and its management (Olayinka 2004). While some information might be available from school and friends, parents should address the practical concerns that puberty brings, for instance, new hygiene needs(e.g., menstrual periods, body odors), clothing and product needs (e.g., cloth vs. napkin brands). In order for girls to live healthy reproductive and dignified life, it is essential that they are able to manage menstrual bleeding effectively (Ahmed & Yesmin 2008). Management of menstruation deals with the special health care needs and requirements like choice of absorbent used, how often and when to change the absorbent used, washing of hands and undergarments, bathing, care of vulva and proper disposal of menstrual wastes. Therefore, menstruation as a regular process needs hygienic management. If poorly managed, menstrual period may be accompanied with discomfort, reproductive tract infections, foul odour and embarrassment among others (Dasgupta & Sarkar (2008). Despite the fact that menstruation is a normal physiological process, it is often associated with some problems and discomforts. Harlow and Campbell (2007), stated that menstrual problem is very traumatic experience for some adolescent girls and women and could truncate their life dreams. Titilayo, Agunbiade, Banjo and Lawani (2009) also stated that 40 -49% of menstruating women are affected by menstrual problems in diverse ways. Studies from different cultures in different parts of the world have associated it with one of the most common causes of regular absenteeism among girls in schools, work places, sports participation and other public functions (El-Gilany, Badawi & ELfedawy 2005; Walraven, Ekpo, Coleman, Scherf, Morrison & Harlow 2002) . Dysmenorrhea is the commonest disorder among girls during menstruation. Others are excessive bleeding, irregular menses, breast pains and fullness. Psychosocial issues surrounding girls during their menstrual periods aggravate these problems (Esimai & Esan 2010; Harlow & Campbell 2007; Antai, Udezi, Ekanem, Okon &  Umoiyoho 2004). In Nigeria, school girls often struggle to manage their menstruation due to social, cultural and economic constraints. Adinma and Adinma (2008) assert that poor knowledge of menstruation and practice engenders reproductive health problems in adolescents such as dysmenorrhoea, depression and reproductive tract infections. In Enugu, girls manage their menstruation and menstrual problems according to the extent of pre menarcheal information they received (Aniebue, Aniebue & Nwankwo 2009). They further stated that socialization brought by western education; parents’ social class influence information girls receive before menarche and in turn affect management of menstruation and menstrual problems. Other issues associated with menstrual hygiene and practices in the country are lack of infrastructure like water, soap, toilet that ensures privacy. Enugu East Town Planning Authority shows that the Local Government comprising both urban and rural population with many secondary school girls; these girls like their counterparts in other parts of the nation may encounter many challenges on issues relating to their sexuality, principally menstruation. Hence, the researcher decided to undertake this study.

Concept of Menstruation

Menstruation is a cyclic uterine bleeding in response to cyclic hormonal changes (Ladewig, London & Olds 2003). Menstruation is the normal, healthy shedding of blood and tissue from the uterus that exits the body through the vagina (Burgers & Lhalungpa 2008). Menstruation is a periodic uterine bleeding through the vagina that occurs with the shedding of the uterine mucosa that signifies one of the signs of puberty, and occurs one or two years following the appearance of secondary sexual characteristics (Oyebola, 2006). Menstruation occurs when the ovum is not fertilized and begins about 14 days after ovulation in a 28 cycle. The menstrual discharge also referred to as the menses, or menstrual flow, is composed of blood mixed with fluid, cervical and vaginal secretions, bacteria, mucus, leucocytes, and other cellular debris. The menstrual discharge is dark and has a distinctive odour ( Ladewig, et al 2003). Menstrual parameters vary greatly among individuals. Generally, menstruation occurs every 28 days plus or minus 5 to 10 days (Abioye- Kuteyi (2000). Emotional and physical factors such as illness, excessive fatigue, stress or anxiety and vigorous exercise can alter the cycle interval. Certain environmental factors such as temperature and altitude may also affect the cycle. The duration of menses is from 2-8 days with the blood loss averaging 30 to 80ml and the loss of iron averaging 0.5 to 1mg daily (Ladewig, et al 2003).

Menstrual Cycle

Menstrual Cycle occurs in four phases; menstrual, proliferative, secretory and Ischaemic phases.

Menstrual Phase:

Menstruation occurs during the menstrual phase, some endometrial areas are shed, while others remain. Some of the remaining tips of the endometrial glands begin to regenerate. The endometrium remains in a resting state following menstruation. Oestrogen levels are low; the endometrium is 1 to 2 mm deep. During this part of the cycle, the cervical mucosa is scanty, viscous and opaque (Cunningham 2000).

The proliferative phase

The phase begins when the endometrial glands enlarge, becoming twisted and longer in response to increasing amounts of oestrogen. The blood vessels become prominent and dilated, the endometrium increases in thickness six to eight folds. This gradual process reaches its peak just before ovulation (Cunningham 2000). If the ovum is fertilized, pregnancy occurs.

The Secretory Phases

This phase follows ovulation. The endometrium, under oestrogenic influence, undergoes slight cellular growth. Progesterone, however causes such marked swelling and growth that the epithelium is wrapped into folds (Scholum & Schater 1996). The amount of tissue glycogen increase, the glandular epithelial cells begin to fill with cellular debris, become twisted and dilate. The glands secrete small quantities of endometrial fluid in preparation for fertilized ovum. The vascularity of the entire uterus increases greatly providing a nourishing bed for implantation. If implantation occurs, the endometrium under the influence of progesterone continues to develop and become even thicker (Ladewig, et al 2003).

Ischaemic Phase

If fertilization does not occur the corpus luteum begins to degenerate, and as a result both oestrogen and progesterone level fall. Areas of necrosis appear under the epithelial lining. Extensive vascular changes also occur. Small blood vessels rupture, and spiral arteries constrict and retract, causing a deficiency of blood in the endometrium, which becomes pale. The ischaemic phase is characterized by escape of blood into the stromal cells of the uterus. The menstrual flow begins, and the menstrual cycle is launched again (Ladewig, et al 2003).

Knowledge about Menstruation

In most developing countries including Nigeria formal education about reproductive health is very limited. In these parts of the world, menstruation and related issues are treated with top secrecy; as a result many young girls lack appropriate and sufficient information regarding menstrual hygiene (Burgers & Lhalungpa 2008, Lawan, Yusuf & Musa 2010). Knowledge of menstruation is typically gained once a girl has reached menarche. Many girls in African society are unaware of menstruation prior to her first experience; because of this, these girls expressed feelings of fear, because they thought they had a wound (Caruso, Freeman, Salim & Fehr 2012). Adinma and Adinma (2008) stated that information girls received in most cases is not adequate to prepare them for menarche, as process and characteristics of menstruation and menstrual cycle are not covered. This to a large extent influences menstrual practices of these adolescent girls. They further stated that the knowledge these girls have about menstruation, function of the reproductive organs and their inter relationships is deficient. Some even perceive menstrual bleeding as emanating from abdomen, intestine and even liver or occurring as a result of curse from gods, sin and disease. Mahon and Fernandes (2010) in a survey conducted in Nepal discovered that most girls have heard about menstruation, but majority are not prepared in any way for their first period (menarche). A common belief among girls was that menstruation was removal of bad blood from the body necessary to prevent infection. The major source of information about menstruation in developing countries is from mothers, sisters and friends. The information most girls receive is regarding the use of pieces of cloths in absorbing their menstrual bleeding, the practice of rituals, the concept of cultural pollution and cautions about their behavior toward men and boys (Mahon & Fernandes 2010). The deficient information affects menstrual hygiene practices and management of menstrual problems.

Management of menstruation

All females have to cope with menstruation that is a natural process in women’s life. From physical and psychological point of view menstruation needs special care (Israr 2010). A key priority for women and girls is to have the necessary knowledge, facilities and cultural environment to manage menstruation hygienically and with dignity. This will be discussed under the following: menstrual hygiene and challenges of managing menstruation.

Menstrual hygiene

Menstrual hygiene refers to ways women keep clean and healthy during menstruation and how they acquire, use and dispose of blood absorbing materials (Bhardwaj & Patkar, 2004). Menstrual hygiene is an issue that every girl and woman has to deal with once she enters adolescence until she reaches menopause (Burgers & Lhalungpa, 2008). Mahon and Fernandes (2010), asserts that in order for women to live a healthy productive and dignified lives, it is essential that they are able to manage menstrual bleeding effectively. This requires absorbent material to soak menstrual blood, access to appropriate water sanitation and hygiene services, including clean water for washing their undergarments and piece of cloths for absorbing menstrual blood and having a place to dry them, including washing of hands before and after change of absorbent materials, having somewhere private to change cloths and pads, access to information to understand the menstruation and menstrual hygiene. Girls need to change their sanitary napkins regularly during the period of menstruation especially in the first two to three days. Hygiene related practices of women during menstruation are of considerable importance, as it has a health implication in terms of increased vulnerability to reproductive tract infections (Sarka & Dasgupta 2008). Good menstrual hygiene is therefore crucial for the health, education and dignity of girls and women. Menstrual hygiene also has an environmental impact, in the form of a growing waste problem. In developing countries, which frequently have poor waste management infrastructure, this type of waste generates a lot of problems. For this reason, encouraging menstrual hygiene in developing countries must be accompanied with calculated waste management strategies.

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Feminine hygiene Materials

Secondary school girls have to choose from varieties of available absorbents. The choice is influenced by cost, availability of the material. Bhardwaj and Patkar (2004) assert that most African school girls cannot afford commercial sanitary pads because the cost of pads is often greater than US$1, which is a daily earning of some parents. These girls are left with the option of using pieces of rags that may be dirty. These cloth pads are washed and used several times. There is no private place to change and clean them and often no safe water and soap to wash them properly. A culture of shame and embarrassment forces them to seek for well hidden places even in their homes to dry these clothes. These places are often damp, dark and unhealthy. This practice is responsible for a significant proportion of illness and infection associated with female reproductive health. Very often, serious infections are left untreated leading to gynaeclolgical conseqences (Burgers & Lhalungpa 2008).

Types of menstrual absorbent materials

There are many types of menstrual absorbent materials available, some are hygienic and some unhygienic.

Sanitary Pads:

Sanitary pads are pieces of absorbent material placed in the crotch of the under wear to collect menstrual blood. They come in different styles, sizes and thickness. Modern pads have flaps or ‘wings’ that wrap around and attach to the undersides of the under garments to ensure adequate protection.

Tampons:

Tampons are tubes of tightly fitted packed cotton that are inserted into vagina. In contrast to externally worn products that are simply fixed in the underwear, tampons require a more detailed knowledge of the female anatomy. The principle function of tampons is to absorb the menstrual fluid inside the body (vagina) after it has left the uterus, thus offering very discreet protection. Tampons come in different versions; either they are inserted with the finger (digital tampons) or with an insertion aid (applicator). Tampons can be used throughout the reproductive age starting with the first menstrual bleeding (menarche) of young girls (on average around the age of 12) until the last menstrual bleeding (menopause) usually around 50. While the monthly bleeding usually lasts between 4 to 7 days, in total, a woman will menstruate for an equivalent of, on average, 6 to 7 years during her life. To meet the individual menstrual protection needs of women due to variances in menstrual bleeding patterns, tampons with different absorbent capacities are offered (Tampon Working Group of Edana 2004).

Menstrual cups:

This is made from gum rubber (natural latex) or silicone; a menstrual cup is made to worn internally within female body and it collects up to one full ounce of menstrual blood. This is an alternative to disposable menstrual products. Menstrual cup are flexible and long lasting. It is a cost effective alternative product with proper care.

How to wear menstrual cup: It follows the normal shape of a female body’s\internal structure. Before inserting, the cup sides are pressed together once and folded in half and then folded again into quarters. When inserted properly it is held by the muscles of the vaginal wall.

Cleaning and maintenance: Proper cleaning is very important to prevent habouring microrganisms. Menstrual cup should be washed with a gentle soap solution before and after each period. It should not be boiled or bleaches as this destroys it and can cause a crack, hardening or breakage (Community Pharmacy Group 2011).

Clean cloth:

These are cut to fit in the panty area by sewing several layers of cotton rags on top of each other. These must be clean. They must be washed thoroughly and hung in a private but sunny place to dry. They should not be shared with others (Burgers & Lhalungpa 2008). Pieces of cloths can be hygienic or unhygienic depending on how they are washed, dried and stored.

Tissue papers: Toilet paper are rolled into a pad and placed at the crotch of undergarments to absorb menstrual wastes. It does not protect the cloths from stains like sanitary pads. It is not very hygienic and pieces of it can enter into the vagina and could cause infection. Whatever a girl uses (cloth, toilet tissue, or pads), she should change it frequently to avoid stains, odour and infections. Girls need to change their napkins regularly during the period of menstruation especially in the first three days.

Disposal of menstrual wastes

Proper disposal of menstrual wastes is essential in order to ensure sustainable management of menstrual waste. Whether it is a cloth napkin or a disposable napkin, efforts must be taken that they are properly disposed. At home, one can dig a hole at the backyard and dump the sanitary pad/cloth/ napkin for drying and then burn it. Leaving it within the sand will delay decomposition and animals may drag it outside. The common disposal of single napkins is to wash the napkin and then wrap it in a newspaper/waste paper. Drop it into bins provided in the toilets. It is advisable for all toilets used by women to have such bins and some wrapping paper to ensure proper disposal mechanisms. Flushing it in toilets should not be done as they clog the drains. In schools especially, disposal of sanitary cloth and sanitary napkins in girls’ toilets is a big problem. It affects the proper functioning of the toilets when disposed in the toilet and serious health\ problems if thrown out in garbage dumps or in the open. In school and other public toilets this is one serious problem to contend. Often we see indiscriminate throwing of menstrual waste in the drains/toilet, thus leaving them clogged. Even in public toilets, it is better to wrap menstrual waste in paper and drop them in dustbins for disposal (Burgers & Lhalungpa 2008).

Challenges girls experience in management of their menstruation

The challenges are as follows: lack of access to feminine hygiene products, lack or poor infrastructure and menstrual taboo/cultural and religious beliefs

Lack of access to feminine hygiene products:

According to Ahmed and Yesmin (2008), materials needed to maintain good hygiene during menstruation were generally found to be lacking. Majority of females especially in rural areas use reusable clothes from torn old cloths to absorb menstrual blood. In order to kill harmful bacteria that can cause infection, cloths should be washed with soap and dried under sunlight. Yet some of the girls and women cannot afford soap to wash the piece of cloths very well. Most often women and girls hid the cloths from sight of men thereby drying them in damp and unhygienic areas. Consequently, they use damp or wet cloths to absorb menses which could be a source of infection. In some of the rural communities, girls could not afford some of the feminine products because of poverty. In a study carried out in south Asia use of sanitary pads was higher among urban School Girls. The reason girls gave for not using sanitary pads, included lack of awareness about sanitary pads, high cost, unavailability and lack of disposal facilities (Mahon et al 2010). Pilliteri (2011) stated that girls believed that cheap, disposable pads could help them manage menstruation better at school and improve school attendance.

Lack or poor infrastructure

Lack of facilities, including safe water and clean toilets that provide privacy, affect good menstrual hygiene practices. Many women and girls do not have a place to change their absorbent or wash their hands with soap and water after change of absorbents especially in schools and work place (Dhingra, Kumar and Kour 2009). In many schools there are no toilet facilities, or the condition of the toilets is too unhygienic to provide a place for change of absorbents. In addition to poor condition of toilets is that toilet/ students ratio is grossly deficient leading to overuse (Pilliteri 2011). Lack of good waste disposal system for menstrual wastes is also another challenge in developing countries. Menstrual wastes supposed to be disposed properly to avoid interaction with the natural environment (soil, water, and air) that disturb the environment and will certainly generate larger problems. Therefore, menstrual hygiene in developing countries must be accompanied with calculated waste management strategies (Israr 2010). Pilliteri (2011), in schools in Malawi, the condition of toilet and lack of disposal facilities often cause indiscrimination littering of the surroundings with sanitary wastes and feaces which is usually unsightly. He also stated that water closets of the school toilets are often clogged with sanitary wastes. (Burgers and Lhalungpa 2008), suggested that all toilets used by women to have such bins and some wrapping paper to ensure proper disposal mechanisms. Also, innovative low cost technology of incinerators has been developed for proper disposal of sanitary wastes in public/school toilets. This design is simple, safe and cost effective using old drums.

Menstrual taboo/cultural and religious beliefs

Menstrual hygiene is a taboo subject, a topic that many women are not comfortable discussing in public (Thakre et al 2011, Mahon & Fernandes 2010, Israr 2010). Myth, mystery and superstition have long enveloped the facts about menstruation. In India even mere mention of the topic has been a taboo in the past and even to this date the cultural and social influences appear to be hurdle for advancement of the knowledge of the subject. The social practices about menstruation make girl child feel subnormal and may hamper her development. Menarche may remain a traumatic event for her unless she is prepared for it (Deo & Ghattargi 2005). Although there are differences by country, culture, ethnic group, social class or family, the oppression of women has it effects on issues concerning menstruation and other issues related to reproductive health and its functions and processes. Women and girls experience a lot of restrictions and control over their mobility, behaviour and daily living during menstruation due to belief of impurity including myths, misconceptions superstitions and cultural/religious taboos concerning menstrual blood and menstrual hygiene (Ten 2007). Some of these religious beliefs are as follows: In Jewish tradition, menstruating women and everything they touch is considered to be impure. Among Hindus menstruation is considered as polluting. During menstrual period, women and girls are not allowed to visit a temple, pray, or cook. They are not allowed to touch anybody and have to stay away from their family because they are seen as impure. The same thing is applicable to Muslims (Ten, 2007). In Bangladesh, menstrual blood is regarded as the greatest of all pollution. Contact with monthly bleeding of a woman cause a new wine to become sour, the harvest become dry, seeds dry out, and fruits of trees fall, the surface of a mirror become dull, sharp edges of metal become blunt, the brilliance of ivory become lusterless, bees dies, iron and bronze starts to rust and air filled with a terrible smell. Dogs that taste menstrual blood, become crazy and their bites are as dangerous as with rabies. As a result, menstruating woman must stay inside as much as possible they are not allowed to cook, or work in the rice or groundnut fields (Kanyike, Akankwasa & Kanengi 2004). In Western Uganda where people rear cows menstruating girls and women were not allowed to drink milk from cows, because it will make the cow to get bloody milk. In Eastern Uganda, menstruating women/girls are not allowed to plant groundnut during planting season because it is believed that menstrual blood affect the yield. In Central Uganda, menstruation was supposed to be top secret known to one self alone (Musinguzi 2006). Ten (2007), asserts that these custom still exist in some Asian, African, and South American cultures. He further stated that in Nigeria menstruating women must isolate themselves in menstruation huts, because it is believed that menstrual blood pollutes the home. Nowadays, a woman does not have to isolate herself during her menstruation periods; however, she must go to a separate part of the house where she lives. Lamb (2006) suggested that there is common misconception that menstrual blood can be used by malevolent person to harm the woman or girl using black magic. It is also believed that a woman can use her menstrual blood to impose her will on a man. Menstruating women must stay inside as much as possible; they are not allowed to prepare food or to work in the rice fields. Sex (and sharing a bed with their partner), praying or reading the Koran are prohibited during this period. All these beliefs result to ill treatment and restrictions women and girls suffer during menstruation (Caruso, Freeman, Salim & Fehr 2012, Ten 2007). However there are some positive rituals regarding menstruation. For different indigenous people, such as: Indians, menstruating women or girls are treated with respect. When Indians are hiking, pauses are planned for menstruating women or girls, so that they can rest and carry out their rituals .Also, the first menstruation of a girl is celebrated. Family, friends and acquaintances are invited for this occasion, special rituals are carried out, and particular dishes are served (Bret 2012, Bosch & Hutter 2002).

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Menstrual problems

Menstrual problems are abnormality that is associated with menstruation. Although menstruation is associated with some degrees of discomforts, where it becomes more severe that it interferes with normal activities or optimal functioning of the individual, it becomes abnormal. Sharma, Malhotra, Taneja and Shah (2002) opine that period of menarche needs special attention because menstruation in adolescent girls is often associated with related problems and poor practices. Menstrual problems have heavy impact in social responsibilities of these adolescents. Some of the problems are: dysmenorrhea, pre-menstrual syndrome (PMS), dysfunctional uterine bleeding.

  Dysmenorrhoea

Dysmenorrhoea is a painful menstruation of sufficient magnitude, so as to incapacitate with day to day activities (Meanal, Kulkari & Druged 2011). Dysmenorrhoea is the commonest health and gynaecological problems and menstrual disorders girls and women of reproductive age face. It is leading cause of recurrent short term school absence in adolescent girls (Agarwal & Agarwal 2010). Dysmenorrhoea is classified into: Primary dysmenorrhea and Secondary dysmenorrhoea.

Primary dysmenorrhoea

This is defined as painful menstruation in woman with normal pelvic anatomy, usually begins during adolescence. It is characterized by pelvic cramps, pain beginning shortly before or the onset of menses and lasting one to three days French 2008; (Hilario, Bozzini, Borsari & Baracat 2008).

Secondary dysmenorrhoea

This pain is caused by a disorder in the woman’s reproductive organs. Pain from secondary dysmenorrhoea usually begins earlier in the menstrual cycle and lasts longer than common cause of secondary dysmenorrhoea are endometriosis, lieomyoma, adenomyosis, ovarian cysts and pelvic congestion (French 2008; Hilario, Bozzini, Borsari & Baracat 2008).

Signs and symptoms of dysmenorrhea

The main symptom of dysmenorrhea is pain concentrated in the lower abdomen, in the umbilical region or the suprapubic region of the abdomen. It is also commonly felt in the right or left abdomen. It may radiate to the thighs and lower back. Symptoms often co-occurring with menstrual pain include nausea and vomiting, diarrhoea or constipation headache, dizziness, disorientation, hypersensitivity to sound, light, smell and touch, fainting, and fatigue. Symptoms of dysmenorrhoea often begin immediately following ovulation and can last until the end of menstruation. This is because dysmenorrhoea is often associated with changes in hormonal levels in the body that occur with ovulation (Hilario et al 2008).

Premenstrual menstrual syndrome (PMS)

Many women feel physical or mood changes during the days before menstruation. When these symptoms happen month after month, and affect a woman’s life, there are known as premenstrual and syndrome ( American College Of Obstetricians and Gynecologists 2011).

Common symptoms of P M S

The symptoms of PMS are both emotional and physical and they are as follows:

Emotional symptoms include: Depression, angry out bursts, irritability, crying spells, anxiety social withdrawal poor Concentration, insomnia, increased nap taking and changes in sexual desire

Physical symptoms include the following: Thirst and appetite changes (Food

cravings), breast tenderness, bloating and weight gain, headache, swelling of the hands or feet, skin problems, gastrointestinal symptoms and abdominal pain.

Diagnosis of P M S

In order to diagnose P MS, a health care provider must confirm a pattern of symptoms. A woman’s symptoms must be present in the 5 days before her period for at least three menstrual cycle end within 4 days after her period for at least three menstrual cycles, end within 4 days after her period starts and interfere with some of her normal activities. To help in the diagnosis the girl is asked to keep record of her symptoms each day for 2-3 months. She should also record the dates of her periods (ACOG 2011).

Premenstrual dysphoric disorder

When symptoms are severe and cause problems with work or personal relationship it is premenstrual dysphonic disorder ( PMDD). PMDD is a severe type of PMS that affects a small percentage of women. This can be treated with serotonin reuptake inhibitors (SSRIS) can help treat PMDD in some women.

Management of dysmenorrhea and PMS

If symptoms are mild to moderate, they can often be relieved by changes in lifestyle or diet. If it is severe that it interferes with one’s life it is best to seek medical advice (ACOG 2011),

Exercise: ACOG asserts that aerobic exercise lessens PMS symptoms. It reduces fatigue and depression. This includes brisk walking, running, cycling and swimming increases heart rate and lungs function. Exercising most days of the week not just during the days of the symptoms will help relieve the symptoms

(ACOG 2011).

Relaxation: Relaxation therapy and reduction of stress will help relieve the symptoms. Relaxation like breathing exercises, meditation, and massage may help. Having enough sleep is very important and will help to reduces the symptoms

Dietary management

Saturated fats should be avoided: limit red meat and dairy products. Avoid fried foods, replace dairy products with soya, rice or oat milk, soya spreads and cheese. Soya products supply phytooestrogen’s to help balance hormone levels. (Mizon, 2011) Replace red meat with fish such as trout salmon, mackerel, and sardines since these provide essential fatty acids (EFA’S) to balance hormones. (Mizon, 2011). Limit sources of caffeine such as Coffee tea, cola replace with herb teas, fruit teas and bottle/filtered water. Caffeine is associated with PMS and increases menstrual pains (Mizon, 2011). Avoid processed / fast foods: since these contains additives and are lower in nutrients required for good hormonal balance (Mizon, 2011). Increase intake of filtered water up to 8 glasses /2 litres daily, will help the liver to detoxify used oestrogen and xenoestrogen (Mizon,2011). Avoid refine carbohydrates and sugar Increase intake of whole grain instead of refined polished food like pasta (spaghetti, macaroni), brown bread instead of white bread to help regulate blood glucose levels. Include a serving of beans or lentils daily. The whole grains, beans or lentils will also raise fibre intake which help to remove used estrogen from the digestive tract so that it cannot be recycled. Increase fibre intake also helps to reduce the levels of unhealthy bacteria in the digestive tract predating the reconjugation and recycling of old oestrogen. These complex carbohydrates as well as lean chicken and turkey will also help to raise tryptophan intake, serotonin and melatonin levels (Mizon, 2011). Increase intake of fruits and vegetables. Reduce salt intake reduce fluid retention that causes bloating. Change eating schedule, eat six small meals instead of large ones.

Drug management of PMS and dysmenorrhea Non ssteroidal anti-inflammatory (NSAIDs) are effective in relieving the pain of primary dysmenorrhea (Archer 2006). They can have side effects like nausea, dyspepsia peptic ulcer, and diarrhoea. Rossi (2006) stated that people, who are unable to take the more common NSAIDs, may be prescribed a COX-inhibitors (Chantler, Mitchell, and Fuller 2008). Besides these drugs anti-spasmodics like buscopam is used that relax the muscles and helps to reduce the pain. Calcium 1,200mg reduces physical and mood symptoms example improvement in mood swings, depression, tension, anxiety, and anger. Magnesium supplement will reduce water retention, breast tenderness and mood symptoms. Vitamin E will help reduce symptoms, Antidepressant:example imipramine, amytrptyline; Diuretics: this is used if water retention is a major problem

Dysfunctional uterine bleeding

(DUB) is abnormal genital tract bleeding based in the uterus and found in the absence of demonstrable structural or organic pathology. It is usually due to hormonal disturbances: reduced levels of progesterone causes menorrhagia. DUB usually occurs either when girls begin to menstruate or when women approach menopause, but it can occur at any time during a woman’s reproductive life. It can be anovulatory or ovulatory DUB (Casablanca, 2008).

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Ovulatory DUB

Ten percent (10%) of cases occur in women who are ovulating, but progesterone secretion is prolonged because estrogen levels are low. This causes irregular shedding of the uterine lining and break-through bleeding. Some evidence has associated Ovulatory DUB with more fragile blood vessels in the uterus. It may represent a possible endocrine dysfunction, resulting in menorrhagia or metrorrhagia. Mid-cycle bleeding may indicate a transient oestrogen decline, while late-cycle bleeding may indicate progesterone deficiency (Casablanca, 2008).

_Anovulatory DUB_

About 90% of DUB events occur when ovulation is not occurring (Anovulatory DUB). Anovulatory menstrual cycles are common at the extremes of reproductive age, such as early puberty and perimenopause (period around menopause). In such cases, women do not properly develop and release a mature egg. When this happens, the corpus luteum, which is a mound of tissue that produces progesterone, does not form. As a result, estrogen is produced continuously, causing an overgrowth of the uterus lining(Casablanca 2008). The period is delayed in such cases, and when it occurs menstruation can be very heavy and prolonged. Sometimes anovulatory DUB is due to a delay in the full maturation of the reproductive system in teenagers. However, the mechanisms are unknown (Bravender & Emans 1999). The cause can be stress, weight (obesity), endocrinopathy neoplasm, drugs, or it may be idiopathic. Assessment of anovulatory DUB should always start with a good medical history, physical examination and laboratory assessment of hormonal profile.

Management of DUB

The goal of therapy should be to arrest bleeding, replace lost iron to avoid anaemia, and prevent future bleeding. Drug of choice is progesterone. Management of dysfunctional uterine bleeding predominantly consists of reassurance, though mid-cycle estrogen and late-cycle progestin can be used for mid- and late-cycle bleeding respectively. Also, non-specific hormonal therapy such as combined high-dose estrogen and high-dose progestin can be given. A hysterectomy may be performed in some cases (Bourdrez , Bongers & Mol 2004).

References

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Adinma, E. D. & Adinma, J. I. B. (2008). Perceptions and practices on menstruations amongst Nigeria secondary school girls. Africa Journal of Reproductive Health 12(1):74- 83.

Ahmed, R. & Yesmin, K. (2008). Menstrual hygiene: breaking the silence, beyond construction use by all. IRC International Water and Sanitation Center and Water Aid.

Aniebue, A. A., Aniebue, P. N. & Nwankwo, T.O (2009). The impact of premenarcheal training on menstrual practices and hygiene of Nigerian school girls. Pan African Medical Journal 2(9).

American College of Obstetricians and Gynecologists (2011). Frequently asked questions, gynecologic problems. FAQ05

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