Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)

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Lecture Outline 1. Normal menstrual cycle 2. Amenorrhea 3. Dysfunctional uterine bleeding (DUB)

Transcript of Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)

Page 1: Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)

Lecture Outline

1. Normal menstrual cycle

2. Amenorrhea

3. Dysfunctional uterine bleeding (DUB)

Page 2: Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)

1. Normal Menstrual Cycle

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Page 4: Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)
Page 5: Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)
Page 6: Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)
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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

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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 .

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2. Amenorrhea

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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.

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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.

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Amenorrhea

• Amenorrhea without Secondary Sexual Characteristics

• Amenorrhea with Secondary Sexual Characteristics and Anatomic Abnormalities

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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

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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.

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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

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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

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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

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3. Dysfunctional Uterine Bleeding (DUB)

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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 .

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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.