TWINNING PROGRAME

REPRODUCTIVE SYSTEM TUTORIAL

TUTOR GUIDE
CASE # 1
TOPIC : MENSTRUAL CYCLE

MISS MAYA DIANA

Date :

18,20,22 Des 2006

Dr.Jusuf S.Effendi,dr,SpOG
Dr.Johanes C.Mose,dr,SpOG-K
R.M.Sonny Sasotya,dr,SpOG
Solihin D, dr., MS
Achadiyani, dr., Mkes
Nina T, dr., SpPK
Ike R Husen, dr.
Dr.Bety
Dr. Setiawan
S
REPRODUCTIVE SYSTEM

BLOCK TITLE
WEEK TITLE
TOPIC

: Reproductive System
: MENSTRUAL CYCLE
: Physiology of Menstruation

WEEK THEME
:
1. Anatomy and histology of uterus and the adnexa
2. Female physiology before pregnancy and female hormones
3. Biochemistry of female sex steroid hormone
4. Endometrial histology in the menstrual cycle
5. Pathogenesis and pathophysiology of menstrual disorders
6. The principles of diagnostic of menstrual disorder
7. The principles of management of menstrual disorder
8. General history taking and physical examination
9. Theories & principles of communication
10. Current & trends of reproductive health problems
11. Natural History of Disease
WEEK OBJECTIVES :
At the end of the week, the students well be able to:
1. Describe the anatomy an histology of uterus and adnexa (Dept. of Anatomy
and histology) (Lab Act)
2. Explain the physiology of menstruation, interaction of related hormones from
hypothalamus, pituitary and ovaries (the H-P-O axis) and its impact on the
endometrium and ovarium (Dept. of Physiology),
3. Explain the structure, synthesis, and mechanism of action of sex
hormone(Dept.of Biochemistry)
4. Explain the definition , etiology, pathogenesis and pathophysiology of
menstrual disorders(Dept. of Obstetrics & Gynecology)
5. Explain interpretation of basic examination in gynecology (Dept. of
Obstetrics & Gynecology) (Skill Lab)
6. Explain the microscopic findings of menstrual disorder (Dept. of Pathology
Anatomy) (Lab Act)
7. Describe the laboratory examination of sex steroid hormone (Dept. of
Clinical Pathology) (Lab Act)
8. Define additional examination in gynecological cases (Dept. of Obstetrics)
9. Explain the diagnosis of the dysfunctional uterine bleeding. (Dept. of
Obstetrics & Gynecology)
10. Elaborate the management plan for dysfunctional uterine bleeding, by using
hormonal and or operative therapy.
11. Explain the pharmacodynamic, pharmacokinetic, indication, contraindication
and side effect of sex steroid hormones therapy. (Dept of Pharmacology)
12. BHP : Theories & principles of communication
13. CHOP: Current & trends of reproductive health problems
14. CRP: Natural History of Disease

INTRODUCTION
Welcome to tutoring in Reproductive week
The case of Maya Diana represents the first week of the Reproductive block. It is
designed for students to learn issues around menstrual cycle and also female reproductive
functions in general. The primary focus of the case is the anatomy, histology, physiology,
of the female
reproductive system and hypothalamic pituitary gonadal axis, end
organ response, as well as pathology anatomy, clinical pathology, pharmacology,
pathophysiology, also to diagnose and recognize the management of menorrhagia in
general, and the usefulness of informed consent.
The case is supplemented by a series of lectures and discusssion including Reproductive
Endocrinology; Theories & principles of communication (BHP) ; Current & trends of
national health problems (Indonesia & Malaysia) (CHOP); Natural History of
Disease (CRP).
CASE SYNOPSIS
Mrs. Maya Diana,a 42-year-old female, suffered from menstrual disorder due to
hormonal imbalance related to age. The most common cause of menstrual disorder is
disfunctional uterine bleeding (DUB) which has 2 type (ovulatoir and anovulatoir).
To diagnose menstrual disorder several examnination should be perform such as
hormonal, gynecologyc exam, etc.
Management of this case is hormonal therapy and may have surgical intervention.
SEQUENCE AND PACING
The case is constructed for 3 tutorial meetings . Although there is some flexibility in the
pacing, the above sequence will allow for a balanced disclosure of information and
appropriate study throughout the week.
MATERIAL (-)

Tutorial I:
Page 1
Mrs. Maya Diana, aged 42 years old, complained of increasingly heavy periods since 3
months ago, attends your clinic where you are the assistant to the doctor in charge as a
doctor in gynecologic clinic. She has three children ages 12, 10 and 8 years.
Previously she had regular menstruation cycle, each one lasting of 5-7 days, but her
cycles have become irregular since three years ago.
Her first menstruation (menarche) occurred at the age of 14, and sign of secondary
sexual development started when she was 13 years old. She never had any complain
during menstruation and denied any mood swing and bloating or any specific changes
before menstruation.

Identity the patient problems.

Generate a hypothesis list and state a rationale for each

What further information may be helpful from Mrs. Maya Diana?

Students are supposed to elicit the following concepts:

a.
Period / Menstruations
b.
Regular period
c.
Irregular periods
d.
Increased heavy periods = menorrhagia
e.
Menarche at age 14
f.
Secondary sexual development at 13
g.
Mood swing and bloating related to menstruation
Hypothesis:
1. Mentrual disorder
2. Uterine tumor
Tutor Guiding questions :
1. What do you know about female periods or menstruation? What is the definition of
menstruation?
2. What are the key aspects of normal menstruation, based on the definition ?
3. How is the regulation of menstruation ?
4. Could you describe how are the female steroid hormones produced?
5. Could you explain the changes of female reproductive system during menstrual
cycles ?
6. What do you know about secondary sexual characteristic and organs involved in the
growth of secondary sexual in female?
7. Why do you think these following statements is important to be asked to the patient?
Patients age
Childhood development

 Secondary sexual characteristic

Tutorial I
Page 2:
Physical examination:
Body weight: 60 kg and height: 170 cm. The women does not appear to be anemic
Vital signs are no specific abnormality
(HR: 94/bpm, RR : 20x/m, T : 370C, BP : 110/80 mmHg)
Head and neck, thorax, abdomen and extremities are no specific abnormality
External examination :
Breast examination : normal
Pelvic examination :
Inspection shows a normal vulva and vagina
Speculum examination shows :
normal portio, fluxus (+)
Vaginal examination :
Portio: normal size and consistency
Uterus : anteverted, mobile, normal sized uterus
No adnexal mass.

Identity the patient problems.

Does the new information change your hypothesis?

What further information do you need?

Problems:
1. Fluxus (+)
2. Portio
3. Uterus: shapes and size
Conclussion:
No specific organs abnormalities
Hypothesis:

Tutorial II
Laboratory Tests :
Haemoglobin = 12.0 gr/dL (NV..)
Leucocyte = 8000/mm3
(NV..)
Platelet count = 215.000/mm3 (NV)
Blood sample taken at 3rd day of periods : (Tutor: first effect of FSH)
Prolactin = 3,9 ng/ml (N= 1 - 20 ng/ml),
FSH = 13,4 IU/L
(N= 5 - 20 IU/L ),
Estradiol : Estrogen = 1 : 5 (N = ?)
Laboratory tests of the liver and kidney functions = within normal limit.
How does this information change your hypothesis?
Identify the patients problems.
Explain the significance of the above physical and laboratory findings.
What further investigations this patient, if any, would be appropriate at this
point?

TUTORS MANUAL
Students are supposed to elicit the following problems:
Interpretation of lab results regarding hormonal examination
New hypothesis:
Menstrualdisorder
Tutors guiding questions :
1. What is your conclusion on gynecological examination findings ?
2. What is your conclusion on the laboratory test?
3. What do you know about menstrual disorders ?
a. Tell us the definition, classification and the etiology of menstrual
disorders!
b. Explain the mechanism of menstrual changes occurring in this patient,
which can result in irregular heavy-periods !

Tutorial II
Page 2
The doctor perform ultrasound examination on 3rd day ofmenstrual cycle and the result
shows:
The size of uterus, and both ovaries were normal.
The thickness of endometrium was 0,4 cm.
No endometrial polyps found.
Based on USG result the doctor suggested to perform curretage.
The pathological finding is dysfunctional uterine bleeding
The doctor explain to the patient about her diagnosis and needs hormonal therapy as a
treatment.

How would you interpret the USG examination ?

How would you act as a doctor in telling the patient?

---------------------------------------------------------------------------------------------------------TUTORS MANUAL
Students are expected to list the problems below :
1.
2.
3.
4.

Endometrial thickness 0.4 cm ( on the 3rd day of menstrual cycle)

endometrial biopsy or microcurettage
Fractional curettage
Doctors suggestion was not done

Tutors guiding questions

1. Why should the doctor perform ultrasonography (or ultrasound scanning) in this
case?
2. What does the result on Endometrial thickness 0.4 cm ( on the 3rd day of menstrual
cycle) mean in this case?
3. What are endometrial biopsy (or microcurettage), and fractional
curettage ? What are the indications for their suggestion ? .
4. Describe what and how a doctor should perform effective communication in doctor
patient relationship

--------------------------------------------------------------------------------------------------TUTORS MANUAL
Students may elicit the following problem
5. Dysfunctional uterine bleeding
6. Hormonal treatment in dysfunctional uterine bleeding (DUB)
Tutors guiding questions :
1. What do you know about DUB ?
2. Who can acquire DUB ?
3. When (at what age group) is DUB mostly found ? What are the incidence of DUB
in the age group ?
4. Explain the pathophysiology (pathogenesis) of DUB !
5. What kind of hormonal therapy can be used in DUB ?
6. How can hormonal therapy can solve DUB ? Explain the mechanism
(pharmacodynamic) of hormonal treatment in DUB !
7. What are the indications, precautions and contraindications (pertaining to
pharmacokinetics, side effects) of hormonal therapy?
8. What kind of surgical therapy can be suggested for DUB ?
9. Who can be advised for surgical therapy in DUB ?
10. When can surgical therapy be done for patients with DUB ?
11. What is your follow up plan for patients undergoing either hormonal or surgical
therapy in DUB cases ?

Tutorial III
Page 1
Epilogue
A week later vaginal bleeding stopped, and her regular menstruation occurred after two
months of treatment.
Reference:
1. Guyton and Hall. Textbook of medical physiology 11th ed. Elsevier
Saunders.2006, pp.1111-1026.
2. Junqueira and Carnaero, Basic histology 10 th ed.the Mac Graw Hills.Companies
Inc., 2003, pp.449-463.
3. Robin and Cotran, Pathologic Basis of Disease 7 th ed. Elsevier Saunders.2005,
pp. 1079-1089.
4. Berek Adashi and Hilard, Novaks 12th ed.William and Wilkims, 2006, pp.158172