1. Lecture Outline 1.Normal menstrual cycle 2.Amenorrhea 3.Dysfunctional uterine bleeding (DUB)

2. 1. Normal Menstrual Cycle

7. Normal Menstrual Cycl e Two segments: the ovarian cycle and the uterine cycle, based on the organ 1.The ovarian cycle: follicular and luteal phases 2.The uterine cycle: proliferative and secretory phases

8. Normal Menstrual Cycl e Normal menstrual : 21 to 35 days, with 2 to 6 days of flow, average blood loss of 20 to 60 mL. Two thirds of adult women have cycles lasting 21 to 35 days. The extremes of reproductive life (after menarche and perimenopause: a higher percentage of anovulatory or irregularly timed cycles.

9. 2. Amenorrhea

10. Amenorrhea Girls have experienced menarche at increasingly younger ages during the past century. Primary amenorrhea : absence of menses 1) at age 13 years when there is no visible secondary sexual characteristic development 2) age 15 years in the presence of normal secondary sexual characteristics. Premature gonadal failure in conjunction with primary amenorrhea: a relatively high incidence of genetic abnormalities (30%). The anatomic causes of amenorrhea : relatively few and the majority by history and physical examination.

11. Amenorrhea The diagnosis of amenorrhea : 1.Physical examination for secondary sexual characteristics and anatomic abnormalities 2.Measurement of human chorionic gonadotropin (hCG) 3.Assessment of follicle stimulating hormone (FSH) levels Therapeutic measures : 1.Specific therapies (medical or surgical) 2.Hormone replacement to 1) initiate and maintain secondary sexual characteristics and 2) provide symptomatic relief, treatments aimed at maintenance of bone mass (bisphosphonates), and ovulation induction for patients desiring pregnancy.

12. Amenorrhea Amenorrhea without Secondary Sexual Characteristics Amenorrhea with Secondary Sexual Characteristics and Anatomic Abnormalities

15. Table 27.1 Amenorrhea Associated with a Lack of Secondary Sexual Characteristics Abnormal physical examination 5-reductase deficiency in XY individual 17,20-desmolase deficiency in XY individual 17α-hydroxylase deficiency in XY individual Hypergonadotropic hypogonadism Gonadal dysgenesis Pure gonadal dysgenesis Partial deletion of X chromosome Sex chromosome mosaicism Environmental and therapeutic ovarian toxins 17α-hydroxylase deficiency in XX individual Galactosemia Other Hypogonadotropic hypogonadism Physiologic delay Kallmann's syndrome Central nervous system tumors Hypothalamic/pituitary dysfunction

16. Table 27.2 Anatomic Causes of Amenorrhea Secondary sexual characteristics present Mullerian anomalies Imperforate hymen Transverse vaginal septum Mayer-Rokitansky-Kuster-Hauser syndrome (all or part of the uterus and vagina (-) in the present of normal sexual characteristics ) Androgen insensitivity True hermaphrodites Absent endometrium Asherman's syndrome Secondary to prior uterine or cervical surgery Currettage, especially postpartum Cone biopsy Loop electroexcision procedure Secondary to infections Pelvic inflammatory disease IUD related Tuberculosis Schistosomiasis IUD, intrauterine device.

17. Table 27.3 Causes of Ovarian Failure after Development of Secondary Sexual Characteristics Chromosomal etiology. Iatrogenic causes. Radiation. Chemotherapy. Surgical alteration of ovarian blood supply. Infections Autoimmune disorders Galactosemia (mild form or heterozygote) Savage syndrome Cigarette smoking Idiopathic

18. Table 27.4 Pituitary and Hypothalamic Lesions Pituitary and hypothalamic Craniopharyngioma Germinoma Tubercular granuloma Sarcoid granuloma Dermoid cyst Pituitary Nonfunctioning adenomas Hormone-secreting adenomas Prolactinoma Cushing's disease Acromegaly Primary hyperthyroidism Infarction Lymphocytic hypophysitis Surgical or radiologic ablations Sheehan's syndrome Diabetic vasculitis

19. Table 27.5 Abnormalities Affecting Release of Gonadotropin?  eleasing Hormone Variable estrogen status a Anorexia nervosa Exercise-induced Stress-induced Pseudocyesis Malnutrition Chronic diseases Diabetes mellitus Renal disorders Pulmonary disorders Liver disease Chronic infections Addison's disease Hyperprolactinemia Thyroid dysfunction Euestrogenic states Obesity Hyperandrogenism Polycystic ovary syndrome Cushing's syndrome Congenital adrenal hyperplasia Androgen-secreting adrenal tumors Androgen-secreting ovarian tumors Granulosa cell tumor Idiopathic

20. 3. Dysfunctional Uterine Bleeding (DUB)

21. Dysfunctional Uterine Bleeding The term dysfunctional uterine bleeding : 1.Abnormal bleeding for which no specific cause has been found. 2.It most often implies a mechanism of an-ovulation, 3.The term is a diagnosis of exclusion, which is probably more confusing than enlightening. 4.Other terms : bleeding abnormalities include an- ovulatory uterine bleeding and abnormal uterine bleeding.

22. Dysfunctional Uterine Bleeding 1.Most an-ovulatory bleeding : termed estrogen breakthrough. 2.In the absence of ovulation and the production of progesterone, the endometrium responds to estrogen stimulation with proliferation. 3.This endometrial growth without periodic shedding results in eventual breakdown of the fragile endometrial tissue. 4.Healing within the endometrium is irregular and dys-synchronous. 5.Relatively low levels of estrogen stimulation will result in irregular and prolonged bleeding 6.Higher sustained levels result in episodes of amenorrhea followed by acute, heavy bleeding.