Lecture Outline
1. Normal menstrual cycle
2. Amenorrhea
3. Dysfunctional uterine bleeding (DUB)
1. Normal Menstrual Cycle
Normal Menstrual Cycle
• Two segments: the ovarian cycle and the uterine cycle, based on the organ
1.The ovarian cycle: follicular and luteal phases
2.The uterine cycle: proliferative and secretory phases
Normal Menstrual Cycle
• Normal menstrual : 21 to 35 days, with 2 to 6 days of flow , average blood loss of 20 to 60 mL.
• Two thirds of adult women have cycles lasting 21 to 35 days.
• The extremes of reproductive life (after menarche and perimenopause: a higher percentage of anovulatory or irregularly timed cycles .
2. Amenorrhea
Amenorrhea
• Girls have experienced menarche at increasingly younger ages during the past century.
• Primary amenorrhea : absence of menses 1) at age 13 years when there is no visible secondary sexual characteristic development 2) age 15 years in the presence of normal secondary sexual characteristics.
• Premature gonadal failure in conjunction with primary amenorrhea: a relatively high incidence of genetic abnormalities (30%).
• The anatomic causes of amenorrhea : relatively few and the majority by history and physical examination.
Amenorrhea
• The diagnosis of amenorrhea : 1. Physical examination for secondary sexual characteristics and
anatomic abnormalities 2. Measurement of human chorionic gonadotropin (hCG) 3. Assessment of follicle stimulating hormone (FSH) levels• Therapeutic measures :1. Specific therapies (medical or surgical) 2. Hormone replacement to 1) initiate and maintain secondary
sexual characteristics and 2) provide symptomatic relief, treatments aimed at maintenance of bone mass (bisphosphonates), and ovulation induction for patients desiring pregnancy.
Amenorrhea
• Amenorrhea without Secondary Sexual Characteristics
• Amenorrhea with Secondary Sexual Characteristics and Anatomic Abnormalities
Table 27.1 Amenorrhea Associated with a Lack of Secondary Sexual Characteristics
Abnormal physical examination
5-reductase deficiency in XY individual
17,20-desmolase deficiency in XY individual
17α-hydroxylase deficiency in XY individual
Hypergonadotropic hypogonadism
Gonadal dysgenesis
Pure gonadal dysgenesis
Partial deletion of X chromosome
Sex chromosome mosaicism
Environmental and therapeutic ovarian toxins
17α-hydroxylase deficiency in XX individual
Galactosemia
Other
Hypogonadotropic hypogonadism
Physiologic delay
Kallmann's syndrome
Central nervous system tumors
Hypothalamic/pituitary dysfunction
Table 27.2 Anatomic Causes of Amenorrhea
Secondary sexual characteristics present
Mullerian anomalies
Imperforate hymen
Transverse vaginal septum
Mayer-Rokitansky-Kuster-Hauser syndrome (all or part of the uterus and vagina (-) in the present of normal sexual characteristics )
Androgen insensitivity
True hermaphrodites
Absent endometrium
Asherman's syndrome
Secondary to prior uterine or cervical surgery
Currettage, especially postpartum
Cone biopsy
Loop electroexcision procedure
Secondary to infections
Pelvic inflammatory disease
IUD related
Tuberculosis
Schistosomiasis
IUD, intrauterine device.
Table 27.3 Causes of Ovarian Failure after Development of Secondary Sexual Characteristics
Chromosomal etiology.
Iatrogenic causes.
Radiation.
Chemotherapy.
Surgical alteration of ovarian blood supply.
Infections
Autoimmune disorders
Galactosemia (mild form or heterozygote)
Savage syndrome
Cigarette smoking
Idiopathic
Table 27.4 Pituitary and Hypothalamic Lesions
Pituitary and hypothalamic
Craniopharyngioma
Germinoma
Tubercular granuloma
Sarcoid granuloma
Dermoid cyst
Pituitary
Nonfunctioning adenomas
Hormone-secreting adenomas
Prolactinoma
Cushing's disease
Acromegaly
Primary hyperthyroidism
Infarction
Lymphocytic hypophysitis
Surgical or radiologic ablations
Sheehan's syndrome
Diabetic vasculitis
Table 27.5 Abnormalities Affecting Release of Gonadotropin?eleasing Hormone
Variable estrogen statusa
Anorexia nervosa Exercise-induced Stress-induced Pseudocyesis Malnutrition Chronic diseases Diabetes mellitus Renal disorders Pulmonary disorders Liver disease Chronic infections Addison's disease Hyperprolactinemia Thyroid dysfunctionEuestrogenic states Obesity Hyperandrogenism Polycystic ovary syndrome Cushing's syndrome Congenital adrenal hyperplasia Androgen-secreting adrenal tumors Androgen-secreting ovarian tumors Granulosa cell tumor Idiopathic
3. Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding
• The term dysfunctional uterine bleeding :1. Abnormal bleeding for which no specific cause has
been found. 2. It most often implies a mechanism of an-ovulation, 3. The term is a diagnosis of exclusion, which is
probably more confusing than enlightening. 4. Other terms : bleeding abnormalities include an-
ovulatory uterine bleeding and abnormal uterine bleeding .
Dysfunctional Uterine Bleeding
1. Most an-ovulatory bleeding : termed estrogen breakthrough.
2. In the absence of ovulation and the production of progesterone, the endometrium responds to estrogen stimulation with proliferation.
3. This endometrial growth without periodic shedding results in eventual breakdown of the fragile endometrial tissue.
4. Healing within the endometrium is irregular and dys-synchronous.
5. Relatively low levels of estrogen stimulation will result in irregular and prolonged bleeding
6. Higher sustained levels result in episodes of amenorrhea followed by acute, heavy bleeding.
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