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Normal Menstrual period is a tough topic for many beginner students. This presentation will help give an insight about the physiological and physical changes during menses as well as physiology of puberty.
Normal Menstrual period is a tough topic for many beginner students. This presentation will help give an insight about the physiological and physical changes during menses as well as physiology of puberty.
Normal Menstrual period is a tough topic for many beginner students. This presentation will help give an insight about the physiological and physical changes during menses as well as physiology of puberty.
Faculty of medicine Al Quds University September, 2012 Normal Menstrual Flow Interval : 21-35 days Duration : 3-7 days Amount 30-60 CC , more than 80cc excessive Normal Menstrual Physiology Hypotalamus GnRH Pituitary gland gonadotropins (FSH, LH). Ovarian follicle Estrogen stimulate endometrium (Proliferative phase) Corpus Luteum progesterone (secretory phase). Endometruim CL degenerate after 14 days decreased progesterone level Endometrial spiral arteriolar spasm break down shedding. Outflow tract.
Axis of Menses Control Hypothalamus
GnRH
Pituitary
FSH, LH
Ovary
Estrogen, Progesterone
Endometrium
Outflow tract Normal Development of Secondary sexual Characteristics 8-9 years Slowest growth rate 9-10 years Thelarche: Breast budding 10-11 years Adrenarch: Pubic and axillary hair 11-12 years Maximal growth rate 12-13 years Menarche: Onset of menses 13-14 years Adult pubic hair 14-15 years Ovulation Amenorrhea Amenorrhea = absence of menstruation Primary amenorrhea = failure of menarche to occur before 16 years of age or within 4 years of thelarche No menses by age 14 years, and absence of secondary sex characteristics. No menses by age 16 years, with presence of secondary sex characteristics. Secondary Amenorrhea = cessation of menses for at least 6 months in a premenopausal woman No menses for 3 months, if previous menses were regular No menses for 6 months, if previous menses were irregular Causes of amenorrhea 1. Pregnancy 2. Genital tract abnormalities Congenital: Imperforated hymen Congenital absence of vagina or cervix Absence of the mullerian duct Acquired : Cervical obstruction/stenosis Intrauterine adhesions Causes of amenorrhea 3. Ovarian failure Gonadal dysgenesis (45X,46XX, 46XY) Premature ovarian failure (postpubertal) 4. Pituitary disorders Hyperprolactinemia Tumors Sheehan syndrome 5. Hypothalamic disorders Stress (weight loss, exercise, emotional) Congenital (Kallmann syndorme) 6. Polycystic ovary syndrome
Investigations FSH level , LH level : If FSH, LH ovarian cause. If FSH, LH pituitary or hypothalamic. HCG to R/O pregnancy. U/S for ovary, uterine abnormality. Challenge Tests. Progesterone challenge test 150 mg parenteral progesterone / or medroxyprogesterone acetate 10 mg for 5 days. Positive withdrawal response anovulatory. Negative withdrawal response: obstruction (e.g., cervical stenosis), or intrauterine adhesions (e.g., Ashermans syndrome). Inadequate estrogen.
Combined estrogen and progestin Challenge test Oral conjugated estrogens 1.25 mg for 21 days combined with oral medroxyprogesterone acetate 10 mg for the last 5 days. Positive response : 2-7 days inadequate estrogen production. The ovaries do not contain adequate function follicles. Folicles are present but there is inadequate pituitary gonadotrpic stimulation. Negative : Obstruction or defect in the endometrium
Terminology of Abnormal Bleeding Oligomenorrhea = bleeding at intervals 40 days that usually is irregular. Polymenorrhea = bleeding at intervals 22 days that may be regular or irregular. Menorrhagia = bleeding that is excessive in both amount and duration at regular intervals. Metrorrhagia = bleeding of usually normal amount but at irregular intervals.
Terminology of Abnormal Bleeding Menometrorrhagia = bleeding that is excessive in amount, is prolonged in duration, and may occur at regular or irregular intervals. Hypomenorrhea = regular uterine bleeding in decreased amount. Intermenstrual bleeding = bleeding that occurs between what is otherwise regular menstrual bleeding. Bleeding in the Reproductive Years DUB dysfunctional uterine bleeding Only use if no other organic cause of bleeding is found. Organic Pathology: Pregnancy (intrauterine or ectopic) Neoplasia Genital tract Cx, endometrial, ovarian, tube etc. Othe CNS, adrenal, thyroid.
Organic Pathology Causing Bleeding in Reproductive Yrs Iatrogenic IUD Drug use Hormones Nonhormonal effects dopamine metab (phenothiazines, TCAs, reserpine, alphamethyldopa.
Oligomenorrhea Regular frequency. Normal amount and duration. Cycle > 35 days. Causes Anovulation is the most common cause. Resistant ovary syndrome. PCOD, Hyperprolactinemia.
Treatment Oligmenorrhea Combined OCP Progesterone Estrogen alone > 3 months Endometrial hyperplasia risk of endometrial CA.
Polymenorrhea Regular frequency Normal amount and duration Cycle < 21days
Give OCP return to normal Exclude polyps or fibroid
Menorrhagia Regular frequency amount and duration > 180 cc /day Cycle 21-35 days Hx of clots with menses
Etiology Idiopathic 90% Organic causes 10% Fibroid Vonwillibrand dz. Pelvic infection Trauma Most common indications of hystrectomy. Treatment Medical: Anti PG Mefanemic (NSAIDs) Compound OCP Hexacaprone (Anti fibrinolytic) Surgical: Hysterectomy Endometrial ablation Thermal Laser Balloon
Dysmenorrhia Painful menstrual periods
50% Of menstruating woman
10% Sever symptoms Classification Primary: - Occurs in young woman within 2y of menarche - Familial predisposition - Excessive myometrial contractions due to progesterone withdrawal resulting in uterine ischemia uterine attack - No pelvic pathology MANAGEMENT : NSAIDs or OC. Secondary : - after ovulatory cycle - Associated with pelvic pathology - Causes : 1- Endometriosis 2- Cervical stenosis 3- Pelvic congestion syndrome 4- Ovarian cysts 5- Uterine leiomyomas 6- PID MANAGEMENT DEPEND ON DIAGNOSIS Abnormal Uterine Bleeding Vagina & vulva : atrophy, trauma, infec., malignancy Cerivx : Erosion, inf., polyps, malignancy. Uterus : 1 st trimester bleeding, leiomyomas, adenomyosis, hyperplasia, malignancy Oviducts : salpingitis ectopic pregnancy Ovaries : estrogen-producing tumors, CA Clinical Work Up -hCG -evaluation of the cycle : 1- ovulatory cycles 2- unovulatory cycles
Ovulatory cycle Regular & predictable Basal body temp. (BBT) shows med cycle elevation. Serum progesterone > 500 ng/dl. Endometrial biopsy shows secretory changes Unovulatory cycle Not predictable & irregular. Monophasic BBT. DUB : in the extremes of reproductive years.
Polycystic ovary disease (stein leventhal syndrome) Def. endocrinological and gynecological dz. Characterized by: Excessive androgen production Prolonged anovulation Multiple fluid filled cystic lesions of ovary Epidemiology: Up to 22% of women So some says its a variant of normal. Pathogenesis Exactly unknown Defect in ovarian maturation
Clinical Presentation Symptoms : An ovulation oligomenorrhea Infertility Hirsutism Dysfunctional uterine bleeding (DUB) Laboratory : androgen LH / FSH ration 3 15 % of high prolactin level
Ultrasound : - necklace sign of ovary : small follicular cysts of peripheral distribution Premenstrual syndrome 90% of women has some degree of PS Symptoms present in the 2 nd half of menstrual cycle. No symptoms at 1 st week. Symptoms are recurrent at least 3 consecutive cycles. Symptoms are severe sometimes and require treatment. Management Of PS Nutrition. Life style. Medication : -selective serotonin re uptake. inhibitors (SSRIs) = prozac. -diuretics = spironolactone. -NSAIDs. -promocriptine.