Menstrual dysfunction

Functional components of menstruation hypothalamus, pituitary, ovary, outflow tract, feedback mechanism

Primary amenorrhea is defined as the absence of menses by 16 years of age in the presence of normal secondary sexual characteristics, or by 14 years of age when there is no visible secondary sexual characteristic development. Secondary amenorrhea - absence of menses for 6 months in a previously menstruating female

Amenorrhea 1. Genuine & false 2. Primary & secondary 3. Physiological & pathological 4. The hypothalamic amenorrhea, The pituitary amenorrhea, The ovarian amenorrhea, The uterine form of amenorrhea.

The hypothalamic amenorrhea Psychogenic amenorrhea Amenorrhea during falls pregnancy Amenorrhea as a symptom of nervous anorexia Amenorrhea as a symptom of adiposogenital dystrophy Amenorrhea as a symptom of the Lorence-Moon-Barde-Bidle syndrome Amenorrhea as a symptom of the Morghani_Stuart syndrome Amenorrhea as a symptom of the persistent lactation syndrome (the Kiari-Fromel syndrome)

Psychogenic amenorrhea Appears as a result of stress situation or psychic traumas Excessive production of corticotropin within stress blocs production of releasing hormones by Hypotalamus. Treatment: psychotherapy, sedative remedies, physiotherapy. After 2-3 months of treatment without result we prescribe thyroidin.

Amenorrhea during falls pregnancy Appears in women, who are eager or very afraid to become pregnant. Clinical features: Nausea Morning vomiting Swelling of breast Some enlarging & softening of uterus can appear But all test for pregnancy are negative.

Anorexia Nervosa Onset between ages 10 and 30. Weight loss of 25% or weight 15% below normal for age and height. Special attitudes: — Denial, — Distorted body image, — Unusual hoarding or handling of food. At least one of the following: — Lanugo, — Bradycardia, — Overactivity, — Episodes of overeating (bulimia), — Vomiting, which may be self-induced. Amenorrhea. No known medical illness. No other psychiatric disorder. Other characteristics: — Constipation, — Low blood pressure, — Hypercarotenemia, — Diabetes insipidus.

Cessation of menstrual cycle via endurance activities, inadequate body weight, eating disorder, stress Reestablish normal hormone levels via diet and exercise counseling, hormone therapy Anorexia Nervosa

Female Athlete Triad Eating disorder/disordered eating Amenorrhea Osteoporosis

Amenorrhea as a symptom of adiposogenital dystrophy It is usually associated with tumours of the hypothalamus , causing increased appetite and depressed secretion of gonadotropin . It seems to affect males mostly. Is a condition characterized by Feminine obesity Growth retardation and retarded sexual development , atrophy or hypoplasia of the gonads , and altered secondary sex characteristics , headaches mental retardation , problems with vision polyuria , polydipsia .

tumours of the hypothalamus Diagrammatic representation of empty sella syndrome. A, Normal anatomic relationship. B, C, and D, Progression in development of empty sella syndrome. Note thinning of floor and symmetric enlargement of sella turcica.

Amenorrhea as a symptom of the Laurence-Moon-Barde-Bidle syndrome Laurence-Moon syndrome comprises Onset in childhood. Inheritance is autosomal recessive. retinitis pigmentosa, initially, problem of night vision; then central vision and then peripheral vision loss progressing to blindness. mental retardation, stunted stature hypogonadism. Spinocerebellar ataxia and progressive spastic paraplegia The complete syndrome is seldom observed in the same individual, but the features are often scattered among the siblings of one family or generation. Members of these families have an increased number of miscarriages and early deaths.

Amenorrhea as a symptom of the Morghani-Stuart syndrome The main features of this hereditary syndrome are: 1) hyperostosis frontalis interna, 2) adipositas, 3) virilism and hirsutism 4) menstrual disorders Treatment is symptomatic

Hyperprolactinemia has such causes: -prolactin-secreting pituitary adenomas -other pituitary or hypothalamic tumors that may distort the portal circulation and thereby prevent effective delivery of hypothalamic dopamine (the putative prolactin inhibitory factor or hormone) -a variety of drugs that lower dopamine levels or inhibit dopamine action (amphetamines, benzodiazepines, butyrophenones, metoclopramide, methyldopa, opiates, phenothiazines, reserpine, and tricyclic antidepressants) -breast or chest wall surgery, cervical spine lesions, or herpes zoster (activation of the afferent sensory neural pathway that stimulates prolactin secretion, in a manner similar to suckling) -hypothyroidism (increased hypothalamic thyrotropin-releasing hormone stimulates pituitary prolactin secretion directly) -pharmacologic estrogens (OCP) -other rare, nonpituitary sources (lung and renal tumors) or causes of decreased prolactin clearance (renal failure).

The pituitary amenorrhea Amenorrhea as a symptom of pituitary nanism Amenorrhea as a symptom of gigantism and acromegalia Amenorrhea as a symptom of Itsenco-Kushing’s disease Amenorrhea as a symptom of Shichane diseas

Amenorrhea in case of pituitary nanism Disease develops in prenatal period or during the first months of life due to infectious diseases or traumatic damages of anterior part of pituitary. Insufficiency of all its hormones including somatotropin appears as a result. Treatment mainly is in an endocrinologist competence. One should begin treatment in childhood with grows stimulation. Further replacement hormonal therapy is indicated

Amenorrhea in case of gigantism and acromegalia Diseases are caused by Somatotropin hyperprodaction, production of gonadothropic hormones is decreased. Amenorrhea has a secondary character. Treatment. At pituitary tumors rhoentgenotherapy is indicated. For Patients with gigantism estrogen therapy for stopping of excessive growth is prescribed.

Itsenko-Cushing syndrome Clinical features are : fatigue, weakness, abdominal obesity, «buffalo hump» (an excessive deposit of fat over the clavicles and back of the neck), moon-shaped face, nervousness, irritability, depression, amenorrhoea or menstrual irregularity. Most commonly observed in females in childbearing age.

Hirsutism, plethora, abdominal striae, diabetes mellitus, osteoporosis, increased susceptibility to infection, cataracts, renal calculi, senile purpura, proximal myopathy, hypertension may be associated. The syndrome may be recognized soon after birth; children with it have stunted growth. It can also be caused by treatment with corticosteroids. Itsenko-Cushing syndrome

“ Moon face” Plethoric face (NO HIRSUTISM) Supra- clavicular fat pads

Sheehan's Syndrome Acute infarction and necrosis of the pituitary gland due to postpartum hemorrhage and shock is known as Sheehan's syndrome. The symptoms of hypopituitarism are usually seen early in the postpartum period, especially failure of lactation and loss of pubic and axillary hair. Deficiencies in growth hormone and gonadotropins are most common, followed by ACTH, and last, by TSH in frequency. Diabetes insipidus is not usually present. This can be a life-threatening condition, but fortunately, because of good obstetrical care, this syndrome is never encountered by most of us.

The ovarian amenorrhea The Shereshevsky-Terner’s syndrome The Stein-Levental syndrome

What is Turner syndrome? Relatively common disorder caused by the loss of genetic material from one of the sex chromosomes. Affects only females

Genetic causes X chromosome monosomy X chromosome mosaicism X chromosome defects

Clinical features Short stature (143-145cm tall) Loss of ovarian function Hormone imbalances( thyroid, diabetes) Stress and emotional deprivation Diseases affecting the kidneys, heart, lungs or intestines Bone diseases Learning problems( esp. in maths)

Gonadal failure Internal genitalia of patient with gonadal dysgenesis (Turner syndrome), featuring normal but infantile uterus, normal fallopian tubes, and pale, glistening "streak" gonads in both broad ligaments.

Diagnosis Possible during infancy or early childhood A physical exam is the first indication The best test is a karyotype, ie a laboratory test presenting the chromosomes

Treatment Growth hormone therapy Estrogen replacement therapy Cardiac surgery (when needed) In vitro fertilization (to achieve pregnancy) Psychological help

Polycystic Ovarian Syndrome Sagittal section of a polycystic ovary illustrating large number of follicular cysts and thickened stroma.

Pathology an inversion of the normal LH/FSH ratio lack of ovulation increased levels of male hormones ("androgens") insulin resistance

Presentation irregular or absent menstruation/ovulation infertility undesired hair growth and acne small benign cysts on the ovaries increased risk of miscarriage obesity endometrial cancer, heart disease and diabetes

Diagnosis BBT (basal body temperature) B ultrasound: multiple small ovarian cysts enlarged ovary Endometrium biopsy(Curettage ) before menses reveal to proliferative glands Determination of LH,FSH,E2,P,T,PRL ， Ins ， (LH:FSH≧3:1) Laparoscopy

Treatment If pregnancy is desired - cause ovulation anti-strogens(clomiphene) Gonadotropins insulin-lowering agents anti-androgens (agents that lower androgen levels) gonadotropin releasing hormone agonists (GnRHa)

If pregnancy is not desired to reduce the risk of endometrial cancer( birth control pills) cyclical progesterone (MPA, Provera) insulin-lowering agents (metformin ,Glucophage) anti-androgens.

The uterine form of amenorrhea Primary Uterus congenital anomalies Secondary Postinflammation intrauterine synechyas Endometrium trauma Tuberculosis of endometrium

Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis) 15% of primary amenorrhea Normal secondary development & external female genitalia Normal female range testosterone level Absent uterus and upper vagina & normal ovaries Karyotype 46-XX 15-30% renal, skeletal and middle ear anomalies

X-ray film of patient with Asherman syndrome. Patient (33 years, gravida 3, para O, abortus 3) had been amenorrheic for 6 months after D&C for most recent therapeutic abortion (TAB). Filling of endocervical canal and nonvisualization of endometrial cavity are consistent with complete obliteration of cavity by adhesions or with obstruction at internal os level by adhesions in lower endometrial cavity. This appearance may also be seen with advanced endometrial tuberculosis. Asherman syndrome

Premenstrual syndrome Symptoms include edema, weight gain, restlessness, irritability, and increased tension. Symptoms must occur in the second half of the menstrual cycle. There must be a symptom-free period of at least 7 days in the first half of the cycle. Symptoms must occur in at least 2 consecutive cycles. Symptoms must be severe enough to require medical advice or treatment.

Mastodynia Pain, and usually swelling, of the breasts caused by edema and engorgement of the vascular and ductal systems is termed mastodynia, or mastalgia. Treatment Management of painful breasts due to fibrocystic changes consists of support of the breasts, avoidance of methylxanthenes (coffee, tea, chocolate, cola drinks), and occasional use of a mild diuretic. Patients with mastodynia have had improvement with danazol, bromocriptine, oral contraceptives, and vitamins, though with limited success. I In one study, lisuride maleate, a dopamine agonist, was associated with a significant decrease in pain.

Dysmenorrhea Dysmenorrhea, or painful menstruation, is the most common complaint of gynecologic patients. There are 3 types of dysmenorrhea: (1) primary (no organic cause), (2) secondary (pathologic cause), (3) membranous (cast of endometrial cavity shed as a single entity).

Typically, pain occurs on the first day of the menses, usually about the time the flow begins, but it may not be present until the second day. Nausea and vomiting, diarrhea, and headache may occur. Dysmenorrhea

Treatment of dysmenorrhea A. ANTIPROSTAGLANDINS B. ORAL CONTRACEPTIVES C. SURGICAL TREATMENT D. ADJUVANT TREATMENTS

Abnormal uterine bleeding Abnormal uterine bleeding includes: abnormal menstrual bleeding bleeding due to other causes such as pregnancy, systemic disease, or cancer.

Patterns of Abnormal Uterine Bleeding Menorrhagia (hypermenorrhea) Hypomenorrhea (cryptomenorrhea) Metrorrhagia (intermenstrual bleeding) Polymenorrhea Menometrorrhagia Oligomenorrhea Contact bleeding (postcoital bleeding)

Evaluation of abnormal uterine bleeding A. HISTORY B. PHYSICAL EXAMINATION C. CYTOLOGIC EXAMINATION D. ENDOMETRIAL BIOPSY E. SALINE HYSTEROSONOGRAM F. HYSTEROSCOPY G. DILATATION AND CURETTAGE H. OTHER DIAGNOSTIC PROCEDURES

Dysfunctional uterine bleeding Treatment A. ADOLESCENTS B. YOUNG WOMEN C. PREMENOPAUSAL WOMEN D. SURGICAL MEASURES

Postmenopausal bleeding Postmenopausal bleeding may be defined as bleeding that occurs after 12 months of amenorrhea in a middle-aged woman. When amenorrhea occurs in a younger person for 1 year and premature ovarian failure or menopause has been diagnosed, episodes of bleeding may be classified as postmenopausal, although resumption of ovulatory cycles can occur.

Gynecologic causes of bleeding A. EXOGENOUS HORMONES B. VAGINAL ATROPHY AND VAGINAL AND VULVAR LESIONS C. TUMORS OF THE REPRODUCTIVE TRACT

Menstrual dysfunction

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