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Uterine prolapse Amenorrhea Dysfunctional uterine bleeding PCOS Infertility Peri-menopause period syndrome

2013/6/11

Zhao aimin MD.Ph.D SSMU

Uterine prolapse

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Definition
The uterus gradually descends in the axis of the vagina taking the vaginal wall with it. It may present clinically at any level, but is usually classified as one of three degrees.
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Degrees of uterine prolapse

First degree:cervix still inside vagina

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Degrees of uterine prolapse

Second degree:the cervix appears outside the
vulva. The cervical lips may become congested and ulcerated

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Degrees of uterine prolapse

Third degree:complete prolapse.In the picture the uterus
is retroflexed,and the outline of bladder can be seen.This is sometimes called complete procidentia.

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Causes
The stretching of muscle and fibrous
tissue
Increased intra-abdominal pressure

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In recent years,the incidence of prolapse

is greatly reduced .The more liberal use of caesarean section and the elimination of labours are probably the two most important factors.

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Symptoms

Something coming down Backache Increased frequency of micturition A bearing down sensation Stress incontinence Coital problems Difficulty in voiding urine
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Treatment
Pessary treatment
Indications
Patient prefers a pessary. Pelvic surgery risks Prolapse amenable to pessary The patient is not fit for surgery Patient wishes to delay operation

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Surgery

Anterior colporrhaphy (and repair of cystocele) Posterior colpoperineorrhaphy (including repair of rectocele) Manchester repair Vaginal hysterectomy
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Dysfunctional Uterine Bleeding

(DUB)

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Definition
an abnormal uterine bleeding without an obvious organic abnormality (neoplasma, pregnancy, inflammation, trauma, blood dyscrasia,hormone adminstrationat el)
unnormal releasing of sex hormones

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Anovulatory functional bleeding ovulatory functional bleeding

DUB occur in before the menopause(50%) after menarche(20%) in reproductive times(30%).

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Anovulatory functional bleeding

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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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Pathology
Change in the endometrium

simple hyperplasia(Cystic hyperplasia , benign) complex hyperplasia(Adenomatous

hyperplasia ,precursor of carcinoma) atypital hyperplasia(10%-25% carcinoma) proliferative phase of endometrium (no secretive change ) atrophic endometrium
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Mechanisms
Anovulation --- have developing folliculi

no mature follicle no corpus luteum only have estrogen, but no progestin breakthrough bleeding, spoting
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Clinical presentation
oligomenorrhea. polymenorrhea hypermenorrhea hypomenorrhea irregular intervals and duration
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Diagnosis
1.History history of age of menarche, initial regularity of cycle, cycle length, amount, duration of flow, parity, contraceptive pill abortion, ectopic pregnancy, endometriosis, pelvic inflammatory disease
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hemorrhagic diseases, endocrinopathies, traumas, nutritional status To decide :the dysfunctional bleeding or anatomic abnormality

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2.physical examination
pelvic vaginal examination (PV)

3.laboratory diagnosis bleed count, coagulation studies, endocrine studies curettage

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Treatment
medicine treatment
1. to

arrest 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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Curettage
for adults rarely use for teenagers unless bleeding is very severe)

aims
1.arrest an acute severe bleeding quickly and effectively 2.to prevent chronic recurrence of DUB 3.diagnosis
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Hysterectomy:
for older patient, never been done in adolescent

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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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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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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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2. Irregular shedding of endometrium

pathology persistent corpus luteum estrogen and progesterone

maintain to effect the endometrium

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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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Treatment
progestin ( 5 days before next

menstruation, feedback) ovulation induction

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Amenorrhea
It is symptom, not a disease

have many causes.

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Definition
Primary amenorrhea lack of menarche by age of 16 years No secondary sexual signs by age of 14 years
Secondary amenorrhea the cessation of menstruation for at least 6 months (or 3 cycles) in women who has her menarche.

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Etiology
Physiologic causes:

childhood pregnancy lactation menopause

Pathologic causes:
1.uterus or lower reproductive tract
endometrial destruction (Ashermans syndrome) cervical stenosis congenital dysgenesis (imperforate hymen, no uterus)

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2.Ovary
ovarian tumor, premature ovarian failure resistant ovary syndrome polycystic ovarian syndrome gonadal dysgenesis
( 75% chromosome abnormality, Turners syndrome,45,XO)

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3.central nervous system hypothalamus pituitary tumors or other organic lesions amenorrhea- galactorrhea syndromes(PRL) empty sella syndrome Sheehan Syndrome hypogonadotropic hypogonadism pituitary insufficiency

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4. psychogenic
psychosis emotional shock pseudocyesis()

5.systemic

chronic disease nutritional disorders hepatic and renal dysfunction

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6. other endocrine cause

adrenal hyperplasia, tumors ,or insufficiency hyperthyroidism or hypothyroidism diabetes mellitus steroidal contraception

7. congenital anatomic
developmental anomalies

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Diagnosis
History physical examination determination : T4 ,T3,TSH, PRL ,E2, P, T, FSH, LH, medicine withdrawal test(step by step) chromoseme test MRI,CT

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No menses
progesterone therapy

PRL

menses no menses Iamenorrhae estrogen progesterone therapy menses (IIamenorrhae) no menses uterus amenorrhea

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 determination of LH ,FSH

high GnRH, low estrogen normal, or low gonadotropins ovarian failure pituitary ,or hypothalamus amenorrhea give GnRH LH ,FSH high hypothalamus amenorrhea LH ,FSH low pituitary amenorrhea

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Treatment
remove etiologic factors estrogen-progesterone therapy achieving normal menstruation, achieving normal sexual function preventing carcinoma ovulation induction (fertility) surgical correction (tumor, congenital anatomic)

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Polycystic Ovary Syndrome (PCOS)

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

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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
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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,PRLIns (LH:FSH3:1) Laparoscopy

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

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 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.

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Peri-menopausal Period Syndrome

(Climacteric Syndrome)

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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 immediately before

and after the menopause.

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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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Peri-menopausal Period Syndrome

peri-menopause accompanied by the symptoms of climacteric, including hot flashes, excessive perspiration, night sweets, 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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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 menopause)

after

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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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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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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 urethrovesical epithelium decreased elastic tone of the uterine and urethrovesical supporting structures

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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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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 occures within 2 months of ovariotomy

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 After natural cessation of ovarian function, bone loss 3% yearly for the first 6 years

By age 65, half of women have bone density decreased by 2 standard deviations below the perimenopausal mean. Beyond age 45, the incidence of wrist fractures is 12 times higher in women than in men of same age

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 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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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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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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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 in tone and are thin Prolapse may be present

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4) Laboratory diagnosis Cytologic smear from the vaginal wall E2, FSH, LH determination Radiography, X-ray densitometry

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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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 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.

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Contraindication
thrombo-embolish hypertension diabetes chronic liver disease myomo, endometriosis, breast disease gallbladder disease

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3) traditional medicine therapy

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Infertility

Lin jianhua

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Definition
defined as not being able to get pregnant despite trying for one year. 10 percent of couples are affected Primary infertility: never conceived Secondary infertility: at least one previous pregnancy

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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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Causes
The incidence of male factors and female factor infertility are similar
Ovary factor 25% (anovulation) Tubal and pelvic factor 25 Uterine factor<5% Cervical factor <5% Male factor 30% Unexplained infertility 15%

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Ovulatory factor
Ovulatory disfunction Anovulatory Amenorrhea

Investigated as follow by means of

Mid-luteal (day 21-23)progesterone in serum Endometrium biopsy at the end of a cycle BBT(basal body temperature) Mid-cycle LH surge in urinary Blood test: LH, FSH, prolactin, thyroid function, androgen *ultrasound
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Anatomical factor:
Tubal disease following pelvic inflammatory disease(PID) Intraperitoneal scarring(PID,endometriosis)

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Uterine factor:
Polyps Submucosal fibroids Endometrial scarring

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Cervical factors:
By mid-cycle(day 13-15) ample clear watery mucus with good stretchability is produced Be favorable to sperm survival

Abnormal cervical factor may relate to poor cycle timing, poor mucus production (surgery,inflammation) an abnormal male factor
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Male factor:
semen analysis Volume 1.5-5.0ml Count>20 million/ml. 40X106/total Initial motility(<1 hour)50% Normal Morphogy>30% No clumping or significant WBC(<1 million/ml)
Information on coital frequency and ejaculatory difficulty should be sought
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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 patency (Hysterosalpingogram, HSG, Laparoscopy) Evaluation of uterine cavity (HSG, Hysteroscopy) Cervical factor (postcoital testing, PCT)
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 Male infertility factor unexplained infertility

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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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 surgery can be done to repair damage to a woman's ovaries, fallopian tubes, or uterus.

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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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 Intrauterine insemination Artificial insemination with husbands sperm (AIH) Artificial insemination by donor (AID)

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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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 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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 Zygote intrafallopian transfer (ZIFT), ICSI (intracytoplasmic sperm injection)

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 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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Key Word

Infertility Ovulation induction ART IVF What are the causes of infertility? Explaining the steps of infertility test.

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