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Obstetrics and Gynecology Clinics


June 2003
   
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 The menstrual cycle represents a complex


interrelationship of hormones and physiologic
events in the brain, ovary and uterus.
 The changes will prepare the body for
implantation or sloughing of the endometrium.
 The average cycle lasts 28 days, separated into 2
phase: follicular and luteal phase.
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 àegins with sloughing of endometrium ,
culminates with ovulation (14 days)
 Marked by development of ovarian follicles and
endometrial growth.
 Predominat hormone is estrogen under influence
of GnRH, FSH, LH, inhibin
 Estrogen (Estradiol) increases until D13-
D13-14 and
lead to a LH surge and ovulation

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 àegins with ovulation culminates with
mentruation or conception
 Marked with follicle transformation to corpus
luteum, produces progesterone
 The Progesterone level increases and reaches
steady state for 11 days.
 In absence of pregnancy, Corpus Luteum
involutes, progesterone decrease and leads to
menstruation
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 Pubertal milestone: onset of menstruation
 Maturation of the HPO axis continues until 5
years of the onset
 Lemarchand
Lemarchand--àeraud:
r ‰ear 1: E,P, FSH, LH: below adult level
r ‰ear 2: Estradiol increases to adult level
r ‰ear 5: FSH, LH increase to adult level, P still low
 The cycle is often irregular initially, but
become more predictable later on
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Disordes of coagulation
Systemic disease
 
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Disorders of reprod
reprod.. tract
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Endocrinopathies
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 Obtain complete medical history, Growth pattern and
pubertal milestone, growth spurt and menarche.
 Record a detailed menstrual pattern.
 Ask a sexual history in non-
non-threatening way .
 If the teen is not sexually active, it gives opportunity to
discuss sexuality issue and explaining about STD¶s.
 Obtain general metabolic parameters (endurance, heat
and cold tolerance, sleep pattern). àody weight
history, rapid changes in body weight.
 Get the family history of bleeding.
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Physical examination:
 Vital sign, including height and weight
 Major body system, especially skin and neurologic
system (for endocrinology and systemic disease)
 Petechial hemorhage or echymosis
 Tanner staging of breast and pubic hair (hormonal
marker)
 Excessive androgen stimulation (acne, hair growth)
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 Should be tailored to age and clinical situation
 Adequate time for explanation, patience, gentleness
during examination
 Speculum may not be necessary in patien who has not
initiated sexual intercourse, except heavy bleeding,
pain an gynec symptom
 If needed speculum, use a narrow, stright blade
speculum
 If suspected sexual activity, take culture
 To assess pelvic mass or pelvic anatomy abormality
perform single digit or recto abdominal exam.
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 Pregnancy test is initial test before beginning any
assessment
  
Complete blood count, differential
Platelet count
Fibrinogen
Prothrombin time
Partial tromboplastin time
àleeding time
 
        
     
von Willebrand factor antigen
Factor VIII activity
Factor XI antigen
Platelet aggregation studies
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 If there is systemic or metabolic disease:
do thyroid, adrenal, other systemic disease
test.
 If there is hyperandrogenism: check T,
DHEAS,17--OH progesteron, Gonadotropin,
DHEAS,17
Fasting insulin and glucose level
 If atipical bleeding :transabdominal USG
 If prolonged bleeding, severe
hyperandrogenism, obesity, carcinoma:
endometrial sampling
 If abnormal anatomy: transperineal USG,
MRI
Treatment
 Goal:
r To identify the source of bleeding and
direct th/
r To stop abnormal bleeding
r To help adolescent have more predictable,
manageable menstrual cycle
 If there is profuse bleeding, hypovolemic,
Hb<9 g/dl resuscitation: volume expansion/
blood product
 The most effective: hormonal therapy (93%
respond)
Treatment
 Hormonal therapy for severe, acute bleeding:
r Conj. Equine estrogen 25mg/4 h, iv
r Continue with CEE 2,5 mg (20-
(20-25 d)
r MPA 10 mg (for the last 7-
7-10 d)
r Or followed by OC
 Antifibrinolytic therapy
 If bleeding prolonged: CEE 2,5 mg (21-
(21-25d)
followed MPA 10 mg (last 7 d) or OC
accelerated dose (2x1 for 1 week, followed
1x1 for 3 weeks)
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Prognosis
 Irregular, unpredictable, heavy bleeding in
adolescent occurs as result of lack of
maturation of HPO axis.
 Over the first 3-
3-5 postmenarchal years,
most will develop regular, cyclic menses.
 If normal menses has not develop in 4
years, the chance for normal menstrual
function is low.
 Many of these women : decreased
reproductive potential, endometrial Ca,
subsequent gynecologic surgery surgery.
Summary
 Abnormal and irregular bleeding are extremely
common in the adolescent period and can be
looked as apart of normal reproductive
development.
 It is essenstial to have a firm grasp on normal,
physiologic development of the menstrual
cycle.
 It is important to recognize the distinc needs,
goals, and development stages of adolescent
patient.
 No single therapy or approach is universal in
the diagnosis and treatment, but must be
tailored to individuals and situation.