26.2008 Reproductive Endocrinology

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  • 1.Zhang Huiying Normal and AbnormalMenstruation Reproductive Endocrinology

2. Main contents

  • Normal manstruation
  • Abnormal uterine bleeding
  • Amenorrhea
  • Perimenopause and perimenopausal syndrome
  • polycystic ovarian syndrome(PCOS)

3. Normal menstruation

  • Mean interval is28 days +/- 7 days.
  • Mean duration is2~7 days.
  • More than 7 days is abnormal.
  • Average blood loss with menstruation is35-50 ml . More than 80 ml is abnormal

4. CNS-Hypothalamus-Pituitary Ovary-uterus Interaction Hypothalamus Gn-RH Ant. pituitary FSH, LH OvariesUterus Progesterone Estrogen Menses ? CNS Notclear 5.

  • The normal menstrual cycle is the result of complex interactions between the hypothalamic- pituitary-ovarian (HPO) endocrine axis.
  • Hypothalamus secrete gonadotropin-releasing hormone,
  • The anterior pituitary release the FSH and LH
  • Every cycle the ovary change fromfollicular development phase to the luteal phasesecrete estrogen and progesterone
  • The endometrium change from proliferative phases to secretory phases. When progesterone and estrogen levels fall with the demise of the corpus luteum, vasoactive substances such as prostaglandins, histamine and bradykinin are produced by the endometrium. Prostaglandins cause spasm of the spiral arterioles which results in ischaemic necrosis and shedding of all but the basal layer of the endometrium.

6. The control of regular menstrual blood loss

  • vasodilatation of spiral arterioles
  • fibrinolytic activity of menstrual blood
  • endometrial regeneration.

7. Abnormal uterine bleeding 8. Sorts of bleeding

  • Abnormal menstrual bleeding
  • Other causes
  • pregnancy
  • Systemicdisease
  • Cancer

9. Patterns of abnormal uterine bleeding

  • Menorrhagia(hypermenorrhea)
  • Hypomenorrhea
  • Metrorrhagia(intermenstrual bleeding)
  • Polymenorrhea
  • Menometrorrhagia
  • Oligomenorrhea
  • Contact bleeding(postcoital bleeding)

10. Menorrhagia

  • Menorrhagia is heavy or prolonged menstrual flow. It is defined as menstrual blood loss exceeding 80 ml per cycle. Submucous myomas adenomyosis IUDs endometrial hyperplasias malignant tumors and dysfunctional bleeding are causes of menorrhagia.

11. Hypomenorrhea

  • Hypomenorrhea is unusually light menstrual flow sometimes only spotting.
  • cervical stenosis and Uterine synechiae Asherman's syndrome can be causative

12. Metrorrhagia

  • Metrorrhagia is bleeding occurring at any time between menstrual periods.
  • Ovulatory bleeding occurs at midcycle as spotting

13. Polymenorrhea

  • Polymenorrhea describes periods that occur too frequently, less than 21 days apart. This is usually associated with anovulation and rarely with a shortened luteal phase in the menstrual cycle.

14. Menometrorrhagia

  • Menometrorrhagia is bleeding that occurs at irregular intervals. The amount and duration of bleeding also vary.
  • Sudden onset of irregular bleeding episodes may be an indication of malignant tumors or complications of pregnancy.

15. Oligomenorrhea

  • Oligomenorrhea describes menstrual periods that occur more than 35 days apart.
  • Bleeding is usually associated with anovulation

16. Contact bleeding(postcoital bleeding)

  • Contact bleeding must be considered a sign of cervical cancer until proved otherwise.

17. Evaluation of abnormal uterine bleeding

  • History
  • Physical examination
  • Cytologic examination
  • Endometrial biopsy
  • Saline hysterosonogram
  • Hysteroscopy
  • Dilatation and curettage(D C)
  • Other diagnostic procedures(assay hCG,pelvic ultrasonography,laparoscopy)

18. History

  • the amount of menstrual flow
  • the length of the menstrual cycle and menstrual period
  • the length and amount of episodes of intermenstrual bleeding
  • any episodes of contact bleeding.
  • the last menstrual period the last normal menstrual period
  • age at menarche and menopause
  • any changes in general health.

19. Physical examination

  • Abdominal masses and an enlarged irregular uterus suggest myoma.
  • A symmetrically enlarged uterus is more typical of adenomyosis or endometrial carcinoma.
  • Atrophic and inflammatory vulvar and vaginal lesions can be visualized
  • cervical polyps and invasive lesions of cervical carcinoma can be seen.
  • Rectovaginal examination is especially important sometimes

20. Cytologic examination -cytologic smears A very useful method to screen the asymptomatic intraepithelial lesions. 21. Endometrial biopsy

  • the Novak suction curet
  • the Duncan curet
  • the Kevorkisn curet
  • the pipelle.

22. Saline hysterosonogram

  • Ultrasound following injection of saline into the uterus has been used to evaluate the endometrial cavity for polyps fibroids or other abnormalities.

23. Hysteroscopy

  • Hysteroscopy Placing an endoscopic camera through the cervix into the endometrial cavity allows direct visualization of the cavity.

24. Dilatation and curettage(D C)

  • DC is the gold standard for the diagnosis of abnormal uterine bleeding.
  • Curettage of the endocervix should be performed before sounding of the endometrial cavity or dilatation of the cervix is done.

25. Other diagnostic procedures

  • assay hCG
  • pelvic ultrasonography
  • laparoscopy

26. abnormal uterine bleeding due to gynecologic diseases and disorders

  • Vulva and vagina --atrophic vulvitis or vaginitis
  • Cervix eversion, cervical polyps, cervical cancer
  • Uterus endometritis,hyperplasias, cancer, submucous myomas,IUD
  • Ovariesestrogen-producing tumor, other cancers

27. Abnormal bleeding due to nongynecologic diseases and disorders

  • Severe hypothyroidism
  • Liver disease
  • Blood dyscrasias and coagulation abnormalities
  • Use anticoagulants or adrenal steroids

28. Dysfunctional uterine bleeding(DUB) 29. definition

  • Dysfunctional uterine bleeding(DUB) is irregular, abnormal uterine bleeding with no demonstrable organic causes. That is not caused by a tumor, infection, or pregnancy. It may be occur during postmenarchal and perimenopausal periods in a woman's reproductive life.
  • Exclusion of pathologic causes of abnormal bleeding establishes the diagnosis of DUB

30.

  • DUBoccur in
  • before the menopause(50%)
  • after menarche(20%)
  • reproductive times(30%)

31.

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

32. Mechanisms

  • have developing folliculi
  • no mature follicle
  • no corpus luteum
  • only have estrogen, but no progestin
  • breakthrough bleeding, spoting

33. pathologicChanges in the endometrium

  • Endometrial hyperplasia
  • Simple hyperplasia
  • Complex hyperplasia
  • Atypical hyperplasia
  • Proliferative phase endometrium
  • Atrophic endometrium

34. 35. Treatment

  • Depends on the age of patient
  • Adolescent
  • Young woman
  • Premenopausal woman

36. Adolescent

  • Acute hemorrhage :high-dose estrogen given intravenously or injection (25mg conjugated estrogen every 4h)
  • Hemodynamically stable patients: take oral conjugated estrogen (2.5mg every 4-6h) or take oral contraceptives 3-4 times the usual dose.

37.

  • Lowerthe dose every 3 days for 1/3 dose after the bleeding stoped and when have lowered to an usual dose, give medroxyprogesterone acetate (MPA)10mg once or twice a day for 10-14d

2.5mg / 6h 2.5mg / 8h 2.5mg / 12h 2.5mg / d Use tobleeding stoped 3d 3d 3d 1.25mg / d 10-14d medroxyprogesterone acetate10-14d 38.

  • Next 3-6 months give cycling theraphy
  • Sequential hormones
  • Oral contraceptive

Adolescent 39. Young women

  • Except the pathologic causes is necessary
  • Hormonal management is the same as for adolescents