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1 Dysfunctional uterine bleeding Infertility Peri-menopausal period syndrome Zhao aimin M.D., Ph.D., Professor Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine

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2 Dysfunctional Uterine Bleeding (DUB)

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3 Definition an abnormal uterine bleeding without an obvious organic abnormality (neoplasma, pregnancy, inflammation, trauma, blood dyscrasia,hormone adminstration at el) unnormal releasing of sex hormones

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4 Anovulatory functional bleeding ovulatory functional bleeding DUB occur in before the menopause(50%) after menarche(20%) in reproductive times(30%)

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5 Anovulatory functional bleeding

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6 Etiology of DUB: 1. disorders of hypothalamus---pituitary ---ovary axis immature of feedback regulation in young women ovarian function failure in climacteric women 2.other Factors: the effects of sex hormones nervous circumstance PCOS,TSH,PRL excessive physical exercise

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7 Pathology Change in the endometrium simple hyperplasia(Cystic hyperplasia, benign) complex hyperplasia(Adenomatous hyperplasia,precursor of carcinoma) atypical hyperplasia(10%-25% carcinoma) proliferative phase of endometrium (no secretive change ) atrophic endometrium

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8 Mechanisms Anovulation ---- have developing folliculi no mature follicle no corpus luteum only have estrogen, but no progestin breakthrough bleeding, spoting

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9 Clinical presentation Menorrhgia ( Polymenorrhea metrorrhgia menometrorrhgia

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10 Diagnosis 1.History history of age of menarche, initial regularity of cycle, cycle length, amount, duration of flow, contraceptive pill abortion, ectopic pregnancy, endometriosis, pelvic inflammatory disease

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11 hemorrhagic diseases, endocrine deseases traumas, nutritional status To decide :the dysfunctional bleeding or anatomic abnormality

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12 2.physical examination pelvic vaginal examination (PV) 3.laboratory diagnosis bleed count, coagulation studies, endocrine studies curettage

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13 Treatment medicine treatment 1. to stop the acute bleeding progesterone--- secretive change, high doses of estrogen---rapid hemostasis 2.maintenance therapy ( restoration of normal menstruation, artificial cyclical therapy ) cyclic estrogen-progestin therapy cyclic low dose oral contraceptive for 3 month ( for adolescent) continue cyclic low dose oral contraceptive,( no fertility demands) 3. induce ovulation Clomiphene, HMG, FSH,GnRH)

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14 Curettage for adults rarely use for teenagers unless bleeding is very severe) aims 1.stop an acute severe bleeding quickly and effectively 2.to prevent chronic recurrence of DUB 3.diagnosis

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15 Hysterectomy: for older patient, never been done in adolescent

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16 Ovulatory functional bleeding A significant percentage of patient is women of childbearing age. 1.Luteal phase defect Pathology : corpus luteum is short-lived luteal phase is short inadequate secretion of progesterone

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17 Clinical presentation polymenorrhea- premenstrual staining diagnosis basal body temperature (BBT)-bi-directional endometrium biopsy specimen taken just before menses reveal to bad for secretive phase

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18 treatment HCG (5000-10000U 14th day) progestin(15th day X 10 days) ovulation induction (Clomiphone, HMG, FSH, mature follicle --- good corpus luteum)

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19 2. Irregular shedding of endometrium pathology persistent corpus luteum estrogen and progesterone maintain to effect the endometrium

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20 Clinical presentation: delayed onset of menses with hypermenorrhea Regular cycles with hypermenorrhea Diagnosis: endometrium biopsy specimen taken on 5th days after the onset of bleeding, reveal a mixture of persistent secretive glands with the proliferative glands

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21 Treatment progestin ( 5 days before next menstruation, feedback) ovulation induction

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22 Peri-menopausal Period Syndrome (Climacteric Syndrome)

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23 Definition Menopause the cessation of menses for a year or more. It is caused by ovarian failure. It marks the end of a womens reproductive life It occurs normally between the ages of 45 55 years and at a mean age of 51 years. It is a physiological process Peri-menopause is a period before and after the menopause.

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24 Premature ovarian failure ----- the cessation of menses before the age of 40 years. Artificial menopause ------ the cessation of menses is secondary to some causes, such as oophorectomy, radiation therapy.

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25 Peri-menopausal Period Syndrome peri-menopause accompanied by the symptoms of climacteric, including hot flashes, excessive perspiration, night sweats, depression, agitation, vaginal dryness, insomnia The basic causes of the climacteric syndrome are a progressive decline in ovarian production on estrogens and other sex hormones

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26 Negative Feedback Secretion of estrogens decreased (ovary) FSH increased (40-45 years old) FSH,LH increased(45-50 years old) FSH increased 14 times LH increased 3 times(menopause) FSH, LH gradually decline (3 years after menopause)

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27 Symptoms and signs 1. Early Symptoms and signs 1) menstraution disorder Oligomenorrhea--- intervals greater than 35 days. Polymenorrhea---- intervals less than 21 days hypermenorrhea amenorrhea menopause

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28 2) vasomotor symptoms( hot flashes, sweats) oestrogen depletion result in instability in the vessels of the skin. The hot flashes begins on the chest and spreads quickly over the neck, face and upper limbs which lasts only seconds but may recur many times one day. Sweat often follows hot flashes.

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29 3) mood changes and sleep disturbances insomnia, headache, backache, depression, hate, having difficulty falling asleep and waking up soon after going to sleep 4)urinary tract problem atrophic change in the urinary epithelium decreased elastic of reproductive and urinary tract supporting structures

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30 5) vaginal dryness and genital tract atrophy atropic vaginitis, dyspareunia the vaginal skin become thin and loses its rugose appearance small red spots appear on the vagina

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31 2. Late symptoms and problems 6)osteoporosis Accelerated bone loss in women is clearly related to the loss of ovarian function. Studies show that a rapid decrease in bone mass occurs within 2 months of ovariotomy

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32 There is now general agreement that postmenopausal osteoporosis is related to estrogen deficiency Estrogen reduce bone resorption more than they reduce bone formation Other factors lack of exercise Malabsorption of calcium

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33 7) cardiovascular lipid changes atherosclerosis( ) HDL ,LDL , total cholesterol , perimenopaual women have a lower incidence of coronary heart disease than men of same age. This observation led to the supposition that estrogen might be a key factor. But recent data suggest that Estrogen has no such protection against heart disease

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34 Diagnosis 1) History menstrual abnormality 2) Symptoms: vasomotor symptoms, vaginal dryness, urinary frequency, insomnia, irritability, anxiety, skin change, breast changes, urinary tract problem, pelvic floor change( cystocele. Rectocele. Prolapse), skeletal change(backache, ) and so on.

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35 3)Physical examination: The clinical findings vary greatly depending on the time elapsed since menopause and the severity of the estrogen deficiency Skin: thin,dry Breast loss turgor The labia are small The uterus becomes much smaller The muscles of the pelvic floor are looser and are thin Prolapse may be present

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36 4) Laboratory diagnosis Cytologic smear from the vaginal wall E2, FSH, LH determination Radiography, X-ray densitometry

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37 Treatment 1) education, understanding, reassurance 2) hormone replacement therapy(HRT) Estrogen therapy The use of estrogens can relieve the menopausal symptoms. The hot flashes, sweats and other complaints disappear or improve within a few days of starting estrogens therapy.

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38 The administration of estrogen without progestogen increases the risk of endometrial cancer and breast cancer. So, correct cyclical therapy, with 10 days progestogen per month, can reduces the incidence of cancer.

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39 Contraindication thrombo-embolish hypertension diabetes chronic liver disease myoma, endometriosis, breast disease gallbladder disease

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40 3) traditional medicine therapy

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41 Infertility

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42 Definition defined as not being able to get pregnant despite trying for one to two years. 10 percent of couples are affected Primary infertility: never conceived Secondary infertility: at least one previous pregnancy

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43 Pregnancy is the result of a chain of events. A woman must release an egg from one of her ovaries (ovulation). The egg must travel through a fallopian tube toward her uterus (womb). A man's sperm must join with (fertilize) the egg along the way. The fertilized egg must then become attached to the inside of the uterus.

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44 Causes The incidence of male factors and female factor infertility are similar Ovary factor 25% (anovulation) Tubal and pelvic factor 25 Uterine factor

48 Male factor: semen analysis Volume 1.5-5.0ml Count>20 million/ml. 40X10 6 /total Initial motility(30% No clumping or significant WBC(

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49 The step of test The assessment of both partners should begin simultaneously History Physical examination Ovulation detection(menstrual history,BBT,serium progesterine,urinary LH,serial ultrasound) Evaluation of tubal function (Hysterosalpingogram, HSG, Laparoscopy) Evaluation of uterine cavity (HSG, Hysteroscopy) Cervical factor (postcoital testing, PCT)

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50 Male infertility factor unexplained infertility

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51 treatment Depending on the test results, different treatments can be suggested Various fertility drugs may be used for women with ovulation problems. should understand the drug's benefits and side effects. Ovulation induction: Clomiphene HMG(human manopausal gonadotropin) FSH(follical stimulating hormone) HCG(human chorionic gonadotropin)

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52 surgery can be done to repair damage to a woman's ovaries, fallopian tubes, or uterus.

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53 Assisted reproductive technology (ART) uses special methods to help infertile couples. ART involves handling both the woman's eggs and the man's sperm. Success rates vary and depend on many factors. ART can be expensive and time-consuming. But ART has made it possible for many couples to have children that otherwise would not have been conceived.

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54 Intrauterine insemination Artificial insemination with husbands sperm (AIH) Artificial insemination by donor (AID)

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55 IVF(in vitro fertilization) 1978 birth of Louise Brown, the world's first "test tube baby. used when a woman's fallopian tubes are blocked or when a man has low sperm counts. A drug is used to stimulate the ovaries to produce multiple eggs. Once mature, the eggs are removed and placed in a culture dish with the man's sperm for fertilization. After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into cells. these fertilized eggs (embryos) are then placed in the woman's uterus

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56 Gamete intrafallopian transfer (GIFT): is similar to IVF, but used when the woman has at least one normal fallopian tube. Three to five eggs are placed in the fallopian tube, along with the man's sperm, for fertilization inside the woman's body.

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57 Zygote intrafallopian transfer (ZIFT), ICSI (intracytoplasmic sperm injection)

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58 ART procedures sometimes involve the use of donor eggs (eggs from another woman) or previously frozen embryos. Donor eggs may be used if a woman has impaired ovaries or has a genetic disease that could be passed on to her baby.

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59 Key Word Infertility Ovulation induction ART IVF What are the causes of infertility? Explaining the steps of infertility test.

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60 Zhao aimin M.D., Ph.D., Professor Department of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine Thanks for Your Attention