Our topics today

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Our topics today

• Uterine prolapse
• Amenorrhea
• Dysfunctional uterine bleeding
• PCOS
• Infertility
• Peri-menopause period syndrome
• Zhao aimin MD.Ph.D
• SSMU

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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 degreecervix still inside vagina

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Degrees of uterine prolapse

• Second degreethe cervix appears outside the
  vulva. The cervical lips may become congested and
  ulcerated

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Degrees of uterine prolapse

• Third degreecomplete 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 adminstration,at 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
  LH ,FSH low
• ?
  ?
• hypothalamus
  pituitary
• amenorrhea
  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,PRL,Ins,(LHFSH?31
  )
• 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 after
  menopause)

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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 factorlt5
• Cervical factor lt5
• 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
• Countgt20 million/ml. 40X106/total
• Initial motility(lt1 hour)50
• Normal Morphogygt30
• No clumping or significant WBC(lt1 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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thank you