Dysfunctional Uterine Bleeding Infertility Peri-menopausal Period Syndrome
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Transcript of Dysfunctional Uterine Bleeding Infertility Peri-menopausal Period Syndrome
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Dysfunctional uterine bleeding
Infertility
Peri-menopausal period syndrome
Zhao aiminM.D., Ph.D., Pro fess orDepartment Of Obstetr ics & Gynecolog y
Renj i Hospita l Affi l ia ted to SJTU School of Medicine
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Dysfunctional Uterine Bleeding
(DUB)
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Definition
an abnormal uter ine bleeding without an
obvious organic abnormali ty (neoplasma,
pregnancy, inf lammation, trauma, blooddyscrasia,hormone adminstrationat el)
unnormal releasing of sex hormones
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Anovulatory functional bleedingovulatory functional bleeding
DUB occur inbefore the menopause(50%)
after menarche(20%)
in reproductive times(30%)
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Anovulatory functional bleeding
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Etiologyof DUB:
1. disorders of
hypo thalamus ---pi tu i tary ---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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Pathology
Change in the endometrium
simple hyperplasia(Cystic hyperplasia , benign)
complex hyperplasia(Adenomatoushyperplasia ,precursor of carcinoma)
atypical hyperplasia(10%-25% carcinoma)
proliferative phase of endometrium (nosecretive change )
atrophic endometrium
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Mechanisms
Anovulation ----
have developing folliculi
no mature follicle
no corpus luteum
only have estrogen, but no
progestin
breakthrough bleeding, spoting
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Clinical presentation
Menorrhgia(Polymenorrheametrorrhgia
menometrorrhgia
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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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hemorrhagic diseases,
endocrine deseases
traumas,
nutritional status
To decide :the dysfunctional bleeding or anatomic
abnormality
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2.physical examinationpelvic vaginal examination (PV)
3.laboratory diagnosis bleed count, coagulation studies,
endocrine studies
curettage
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Treatment
medicine treatment1.to stop theacute 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 ovulationClomiphene, HMG, FSH,GnRH)
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Curettagefor 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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Hysterectomy: for older patient,
never been done in adolescent
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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 ofprogesterone
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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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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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2.Irregular shedding ofendometrium
pathology persistent corpus luteum
estrogen and progesterone
maintain to effect the
endometrium
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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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Treatment progestin ( 5 days before next
menstruation, feedback)
ovulation induction
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Peri-menopausal Period
Syndrome(Climacteric Syndrome)
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Definition
Menopause the cessation of menses for a year or more.
It is caused by ovarian failure.
It marks the end of a womensreproductive life
It occurs normally between the ages of 4555
years and at a mean age of 51 years.
It is a physiological process
Peri-menopause is a period before and after themenopause.
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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 productionon estrogens and other sex hormones
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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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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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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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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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2. Late symptoms and problems
6)osteoporosisAccelerated bone loss in women is clearly
related to the loss of ovarian function.
Studies show that a rapid decrease in bonemass occurs within 2 months of ovariotomy
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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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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 estrogenmight be a key factor.
But recent data suggest that Estrogen has no suchprotection against heart disease
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Diagnosis
1) Historymenstrual abnormality
2) Symptoms: vasomotor symptoms, vaginaldryness, urinary frequency, insomnia,irritability, anxiety, skin change, breastchanges, urinary tract problem, pelvic floorchange( cystocele. Rectocele. Prolapse), skeletal
change(backache, ) and so on.
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3)Physical examination:
The clinical findings vary greatly depending on the timeelapsed since menopause and the severity of theestrogen 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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4) Laboratory diagnosis
Cytologic smear from the vaginal wall
E2, FSH, LH determination
Radiography, X-ray densitometry
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Treatment
1) education, understanding, reassurance
2) hormone replacement therapy(HRT)
Estrogen therapy The use of estrogens can rel ieve the menopausal
symptoms.
The hot f lashes , sweats and other complaints
disappear or improve within a few days ofstar ting estrogens therapy.
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The adminis t rat ion of est rogen wi thout
progestogen increases the r isk of
endometr ial cancerand breast cancer.
So, co rrect cycl ical therapy, w ith 10 days
progestogen per month, can reduces the
incidence of cancer.
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Contraindication
thrombo-embolish
hypertension
diabetes
chronic liver disease
myoma, endometriosis,
breast disease
gallbladder disease
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3) traditional medicine therapy
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Infertility
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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 oneprevious pregnancy
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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 tothe inside of the uterus.
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Causes
The incidence of male factorsand female factor infertility aresimilar
Ovary factor 25% (anovulation)
Tubal and pelvic factor 25 Uterine factor
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Ovulatory factor Ovulatory disfunction
Anovulatory
Amenorrhea
Investigated as follow by means ofMid-luteal (day 21-23)progesterone in serum
Endometrium biopsy at the end of a cycle
BBT(basal body temperature)
Mid-cycle LH surge in urinary
Blood test:LH , FSH, prolactin , thyroid function,androgen
ultrasound
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Anatomical factor:Tubal disease following pelvic
inflammatory disease(PID)
Endometriosis
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Uterine factor:
Polyps
Submucosal myoma
Endometrial scarring
Cervical factors
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Male factor:semen analysis
Volume 1.5-5.0ml
Count>20 million/ml. 40X106/total
Initial motility(30%
No clumping or significant WBC(
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The step of test
The assessment of both partners should begin simultaneously
History
Physical examination
Ovulation detection(menstrual history,BBT,seriumprogester ine,ur inary LH ,ser ial ul trasound)
Evaluation of tubal function (Hysterosalpingogram, HSG,
Laparoscopy)
Evaluation of uterine cavity (HSG, Hysteroscopy) Cervical factor (postcoital testing, PCT)
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Male infertility factor
unexplained infertility
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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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Assisted reproductive technology (ART)
uses special methods to help infertile couples.
ART involves handling both the woman's eggs andthe man's sperm.
Success rates vary and depend on many factors.
ART can be expensive and time-consuming. ButART has made it possible for many couples tohave children that otherwise would not have beenconceived.
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Intrauterine insemination
Artificial insemination with husbands sperm(AIH)
Artificial insemination by donor (AID)
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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 theyhave become fertilized by the sperm and are dividing into
cells.
these fertilized eggs (embryos) are then placed in thewoman's uterus
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Gamete intrafallopian transfer
(GIFT):
is similar to IVF, but used when the
woman has at least one normalfallopian tube.
Three to five eggs are placed in the
fallopian tube, along with the man'ssperm, for fertilization inside the
woman's body.
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Zygote intrafallopian transfer
(ZIFT),
ICSI (intracytoplasmic sperm
injection)
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ART procedures sometimes involvethe 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 passedon to her baby.
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Key Word
Infertility
Ovulation induction
ART
IVF
What are the causes of infertility?
Explaining the steps of infertility
test.
Th k f Y Att ti
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Zhao aiminM.D., Ph.D., Pro fess orDepartment of Obstetr ics & Gyn ecology
Renj i Hospita l Aff i l iated to SJTU Schoo l of Medicine
Thanks for Your Attention