Our topics today Uterine prolapse Amenorrhea Dysfunctional uterine bleeding PCOS Infertility Peri-menopause period syndrome Zhao aimin MD.Ph.D SSMU
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.
Degrees of uterine prolapse • First degree:cervix still inside vagina
Degrees of uterine prolapse • Second degree:the cervix appears outside the vulva. The cervical lips may become congested and ulcerated
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.
Causes • The stretching of muscle and fibrous tissue • Increased intra-abdominal pressure
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.
Symptoms • Something coming down • Backache • Increased frequency of micturition • A ‘bearing down’ sensation • Stress incontinence • Coital problems • Difficulty in voiding urine
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
Surgery • Anterior colporrhaphy (and repair of cystocele) • Posterior colpoperineorrhaphy (including repair of rectocele) • Manchester repair • Vaginal hysterectomy
Definition an abnormal uterine bleeding without an obvious organic abnormality (neoplasma, pregnancy, inflammation, trauma, blood dyscrasia,hormone adminstration，at el) unnormal releasing of sex hormones
Anovulatory functional bleeding ovulatory functional bleeding DUB occur in before the menopause(50%) after menarche(20%) in reproductive times(30%).
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
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
Mechanisms Anovulation ---- • have developing folliculi • no mature follicle • no corpus luteum • only have estrogen, but no progestin • breakthrough bleeding, spoting
Clinical presentation • oligomenorrhea. • polymenorrhea • hypermenorrhea • hypomenorrhea • irregular intervals and duration
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
hemorrhagic diseases, • endocrinopathies, • traumas, • nutritional status To decide :the dysfunctional bleeding or anatomic abnormality
2.physical examination pelvic vaginal examination (PV) 3.laboratory diagnosis • bleed count, coagulation studies, • endocrine studies • curettage
Treatment medicine treatment 1.to arrest theacute 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)
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
Hysterectomy: • for older patient, • never been done in adolescent
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 ofprogesterone
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
treatment • HCG (5000-10000U 14th day) • progestin(15th day X 10 days) • ovulation induction (Clomiphone, HMG, FSH, mature follicle --- good corpus luteum)
2.Irregular shedding of endometrium pathology • persistent corpus luteum • estrogen and progesterone maintain to effect the endometrium
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
Treatment • progestin ( 5 days before next menstruation, feedback) • ovulation induction
Amenorrhea It is symptom, not a disease have many causes.
Definition Primaryamenorrhea • lack of menarche by age of 16 years • No secondary sexual signs by age of 14 years Secondaryamenorrhea the cessation of menstruation for at least 6 months (or 3 cycles) in women who has her menarche.
Etiology Physiologic causes: • childhood • pregnancy • lactation • menopause Pathologic causes: 1.uterus or lower reproductive tract • endometrial destruction (Asherman’s syndrome) • cervical stenosis • congenital dysgenesis (imperforate hymen, no uterus)
2.Ovary • ovarian tumor, • premature ovarian failure • resistant ovary syndrome • polycystic ovarian syndrome • gonadal dysgenesis ( 75% chromosome abnormality, Turner’s syndrome,45,XO)
3.central nervous system hypothalamus – pituitary • tumors or other organic lesions • amenorrhea- galactorrhea syndromes(PRL↑) • empty sella syndrome • Sheehan Syndrome • hypogonadotropic hypogonadism • pituitary insufficiency
4. psychogenic • psychosis • emotional shock • pseudocyesis(假孕) 5.systemic • chronic disease • nutritional disorders • hepatic and renal dysfunction
6. other endocrine cause • adrenal hyperplasia, tumors ,or insufficiency • hyperthyroidism or hypothyroidism • diabetes mellitus • steroidal contraception 7. congenital anatomic • developmental anomalies