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
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
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.
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