Post on 25-Dec-2015
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MENSTRUAL CYCLE It’s a girl thing Understanding the mechanism is critical
to diagnosis and management of reproductive problems
Physiologic and anatomic changes within the cycle
MENSTRUAL CYCLE Coordinated interactions between the
hypothalamus, anterior pituitary gland, ovaries and uterine endometrium
Normally is a 21- 35 day cycle Typically lasts for 2 to 6 days With a 20- 60 ml blood loss
RECALL: MENSTRUAL CYCLE PHYSIOLOGY Ovarian cycle
Follicular phaseLuteal phase
Uterine cycleProliferative phaseSecretory phase
OVARIAN CYCLE
Menarche to menopause
Monthly release of a single mature follicle
Number of oocytes:Fetus: 6-7million by 20
weeks AOGBirth: 1-2 millionPuberty: 300k-400kOvulation: 400-500
FOLLICULAR PHASE FSH secretion recruit 5-7 Graafian follicle FSH proliferation of granulosa cells and
expression of LH receptors Aromatase and p450 activation
granulosa cells secrete estrogen increase in GnRH increase in LH androgen synthesis proliferation, differentiation, secretion follicular thecal cells
High levels of LH results in the luteinization of the granulosa cells, production of progesterone and initiation of ovulation
LUTEAL PHASE: CORPUS LUTEUM• Primary regulator of the luteal phase• Active secretory structures that produce
progesterone• Estrogen and Inhibin A are also produced• Corpus luteum steroids provide negative
feedback and cause decrease in FSH and LH
• Inhibin secretion potentiates FSH withdrawal
• Production of progesterone inhibits further development and recruitment of additional follicles
LUTEAL PHASE• Continued corpus luteum function depends
on continued LH production• Corpus luteum regresses after 12 to 16
days in the absence of stimulation and form: corpora albicans
• As the corpus luteum regresses, progesterone and estrogen levels wane and allows FSH and LH levels to rise again and recruit follicles
• And the cycle begins again
PROLIFERATIVE PHASE Progressive mitotic growth of
decidua functionalis Early endometrium is thin (1-2mm) Straight, narrow, short endometrial
glands Low columnar during early proliferative
phase Pseudostratified pattern before
ovulation Dense complex stroma Infrequent vascular structures
SECRETORY PHASE In a typical 28-day cycle, ovulation
occurs on day 14 Within 48-72 hours, onset of
progesterone secretion produces a change in the histologic appearance in the endometrium
Characterized by cellular effects of Progesterone in addition to Estrogen
Presence of glycogen-containing subnuclear vacuoles
SECRETORY PHASE By day 21
Progressive edemaVisible long and coiled spiral arteries
By day 24Cuffing visible in perivascular stroma
2 days before menses Increase in polymorphonuclear lymphocytesCollapse of endometrial stroma and start of
menstrual flow
MENSES No more glandular secretion Destruction of corpus luteum
Breakdown of decidua functionalis menses
Prostaglandin (PGF-alpha)
WHAT IS ABNORMAL UTERINE BLEEDING?Parameter Normal menstrual
flowAbnormal uterine bleeding
Mean interval between menses
28 days (±7 days) <21 days
Mean duration 4 days >7 days (menorrhagia)
Mean blood loss between 35-80ml (depends on source)
>80ml (hypermenorrhea)
•Excessive uterine bleeding with a demonstrable organic cause•Genital or extragenital
≠ Dysfunctional uterine Bleeding (DUB)
No demonstrable organic cause
AUB FORMSINTERVAL DURATION AMOUNT
OLIGOMENORRHEA Infrequent bleeding 35 days to 6
months scanty
AMENORRHEA Absent No menses for
at least 6 months
Absent
INTERMENSTRUAL or Intercyclic BLEEDING Regular Variable
MENORRHAGIA=HYPERMENORR
HEA Regular >7 days >80 ml
METRORRHAGIA Irregular but infrequent ±prolonged variable
MENO METRORRHAGIA Irregular prolonged excessive
POLYMENORRHEA Regular <21 days
QUANTIFYING MEAN BLOOD LOSS (MBL)• Subjective– Subjective judgment– Number of sanitary pads– Passage of blood clots – Degree of inconvenience
• Objective– Radioisotopic labeling of RBCs– Photometric measurement: most common
• ALKALINE HEMATIN test – very accurate
ORGANIC CAUSES Systemic Diseases
1. Blood Dyscrasias 2. Liver Disease3. Thyroid Problems 4. PCOS (Polycystic Ovarian Syndrome) 5. Medications
ORGANIC CAUSES: SYSTEMIC DISEASES1. Blood Dyscracias– Von Willebrand’s disease
Inherited disorder of platelet dysfunction Most common inherited bleeding disorder menorrhagia
– Disorders of blood coagulation • Prothrombin deficiency
– Platelet deficiency• Leukemia• Severe sepsis• Idiopathic thrombocytopenic purpura• Hypersplenism
ORGANIC CAUSES: SYSTEMIC DISEASES2. Liver Disease
Cirrhosis of the liver Excessive bleeding Reduced capacity of the liver to metabolize
estrogens
ORGANIC CAUSES: SYSTEMIC DISEASES3. Thyroid problems
Hypothyroidism Associated with menorrhagia Intermenstrual bleeding
Hyperthyroidism Usually not associated with menstrual
abnormalities Hypomenorrhea Oligomenorrhea Amenorrhea
ORGANIC CAUSES: SYSTEMIC DISEASES4. Polycystic Ovarian Syndrome
(PCOS)– Common cause of abnormal bleeding in the
adolescent– Diagnosis is based upon clinical and
biochemical criteria• Obesity• Menstrual irregularity• Insulin resistance• Hyperandrogenism– Hirsutism – excessive hair growth– Acne– Clitoromegaly
ORGANIC CAUSES: SYSTEMIC DISEASES5. Medications
Hormonal medicationsAnticoagulants, platelet inhibitorsAndrogens, spironolactonesOral and injectable steroidsPsychotropic drugsMay present with menorrhagiaAbnormal intracycle (in between cycles)
bleeding
REPRODUCTIVE TRACT DISEASE Pregnancy-related problems Cervical problems Uterine problems Ovarian tumors Infection Carcinomas
PREGNANCY Always rule out pregnancy in women of
reproductive age!Serum B-HCG test
Ectopic Pregnancy 1st trimester:
Spontaneous Abortion Complete, Threatened, Incomplete
3rd trimester:Abruptio Placenta vs. Placenta Previa
Abruptio Placenta Placenta Previa
Pathophysiology Separation of normally implanted placenta from attachment to uterus.
Abnormal implantation of placenta near or at cervical os.
Symptoms Painful vaginal bleeding that usually does not spontaneously cease.Abdominal pain.
Painless bright red bleeding that often stops within 1-2 hours.
CERVIX Bleeding occurs after coitus Cervicitis
Foul smelling dischargeSpotted cervix
Endocervical PolypRound protruding mass
Cervical CancerAbnormal pap smearMultiple sexual partnersEarly age of coitus
UTERUS Myoma
Subserous IntramuralSubmucous (presents w/ abnormal
bleeding) Endometrial Polyp Endometrial Carcinoma
Transvaginal ultrasound, hysteroscopically guided biopsy, fractional dilatation and curettage
OVARY
Polycystic ovary syndrome (PCOS) Irregular mensesSigns of androgen excess
(hirsutism)Evidence of polycystic ovaries
by ultrasound “string of pearls”
Ovarian cyst or tumor Endometriosis
INFECTION Pelvic Inflammatory
DiseaseAbdominal painVaginal dischargeVaginal bleeding
Fitz-Hugh-Curtis Syndrome
DYSFUNCTIONAL UTERINE BLEEDING (DUB)
No organic, systemic, iatrogenic cause Disruption in menstrual cycle
Ovulatory Anovulatory
•Increase in amount of PGF2α and PGE2•Increase in endometrial pGF2α/PGE2 ratio from midcycle to menses•Promotes vasoconstriction
•No progesterone production•Reduced (vasoconstriction) PGF2α concentration•PGE2 levels are normal•Decreased PGF2α/PGE2 ratio•Promotes vasodilatation•Why medical treatment works•Heavier or more prolonged bleeding
DIAGNOSIS History and Physical Exam
Organic or dysfunctional in originFamily history (ex. blood dyscrasia)
Laboratory Exam & Radiologic TestPregnancy testCBCCoagulation profileUltrasound
ProceduresDilatation and CurettageHysteroscopy
GOALS Establish or maintenance of
hemodynamic stability Correction of acute or chronic anemia
Treat what is pressing at the moment! Return to a pattern of normal menstrual
cycles Prevention of recurrence Prevention of long-term consequences
MEDICAL MANAGEMENT attempted before surgical management
EstrogensProgesteronesNonsteroidal Anti-inflammatory Drugs
(NSAIDs)Antifibrinolytic Agents Gonadotropin-releasing hormone (GnRH)
agonists
ESTROGENS• for acute management• causes rapid growth of endometrial tissue
over denuded and raw surface• promotes platelet adhesiveness• beneficial if the endometrium is thin < 5 mm • after bleeding stops, estrogen is continued,
along with a progestin for another 7 to 10 days
• regularize menses and also to better the skin
PROGESTERONES Stops endometrial growth allows
sloughing off after the cessation of bleeding
Organized sloughing of endometrium after its withdrawal
Stimulates arachidonic acid production Progesterone IUD
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
Prostaglandin synthetase inhibitors Reduces menstrual blood loss by 50%
Mefenamic acid 500 mg 3x a day Ibuprofen 400 mg 3x a dayMeclofenamate sodium 100 mg 3x a dayNaproxen sodium 275 mg 4x a day
Given on the first 3 days of menses
ANTIFIBRINOLYTIC AGENTS • To prevent further bleeding– not primary meds; just ADJUNCT to
decrease blood loss– beneficial to patients who are ovulating and
have menorrhagia• Examples:– ε–Aminocaproic acid (EACA)– Tranexamic acid (AMCA)– Para-Aminomethylbenzoic acid
ANTIFIBRINOLYTIC AGENTS • Side effects:– Nausea– Dizziness– Diarrhea– Headache– Abdominal pain– Allergic manifestation
• Contraindicated in patients with renal failure
GONADOTROPIN-RELEASING HORMONE (GNRH) AGONISTS
Inhibits ovarian steroidogenesis Cessation of menses Allows temporary management of
bleeding and correction of anemia prior to definitive procedure
• Cannot be used for extended treatment because of risk of osteoporosis
SURGICAL MANAGEMENT should be reserved for situations in
which medical therapy has been unsuccessful or is contraindicatedDilatation and curettage (D and C)Endometrial Ablation Hysterectomy
DILATATION AND CURETTAGE (D AND C)
to denude liningDiagnostic and therapeutic Immediate management of severe bleeding
episode Indicated for hypovolemic women who are
actively bleeding and for older women who are at higher risk of having endometrial hyperplasia
ENDOMETRIAL ABLATION
It destroy endometrium Techniques
roller ball technique: burns the lining thermal balloon: scald the liningmicrowave ablation: fry the liningCryoablation
Amenorrhea in 25% to 60%
ENDOMETRIAL ABLATION
Used for women without uterine lesions who are unresponsive to medical therapy
Alternative to hysterectomy, for patients who are not good candidates for surgery
For patients who do not want to keep their reproductive capacity