Every cycle the ovary change from follicular development phase to the luteal phase secrete estrogen and progesterone
The endometrium change from proliferative phases to secretory phases. When progesterone and estrogen levels fall with the demise of the corpus luteum, vasoactive substances such as prostaglandins, histamine and bradykinin are produced by the endometrium. Prostaglandins cause spasm of the spiral arterioles which results in ischaemic necrosis and shedding of all but the basal layer of the endometrium.
The control of regular menstrual blood loss
vasodilatation of spiral arterioles
fibrinolytic activity of menstrual blood
Abnormal uterine bleeding
Sorts of bleeding
Abnormal menstrual bleeding
Patterns of abnormal uterine bleeding
Contact bleeding(postcoital bleeding)
Menorrhagia is heavy or prolonged menstrual flow. It is defined as menstrual blood loss exceeding 80 ml per cycle. Submucous myomas ， adenomyosis ， IUDs ， endometrial hyperplasias ， malignant tumors ， and dysfunctional bleeding are causes of menorrhagia.
Hypomenorrhea is unusually light menstrual flow ， sometimes only spotting.
cervical stenosis and Uterine synechiae （ Asherman's syndrome ） can be causative
Metrorrhagia is bleeding occurring at any time between menstrual periods.
Ovulatory bleeding occurs at midcycle as spotting
Polymenorrhea describes periods that occur too frequently, less than 21 days apart. This is usually associated with anovulation and rarely with a shortened luteal phase in the menstrual cycle.
Menometrorrhagia is bleeding that occurs at irregular intervals. The amount and duration of bleeding also vary.
Sudden onset of irregular bleeding episodes may be an indication of malignant tumors or complications of pregnancy.
Oligomenorrhea describes menstrual periods that occur more than 35 days apart.
Bleeding is usually associated with anovulation
Contact bleeding(postcoital bleeding)
Contact bleeding must be considered a sign of cervical cancer until proved otherwise.
Evaluation of abnormal uterine bleeding
Dilatation and curettage(D ＆ C)
Other diagnostic procedures(assay hCG,pelvic ultrasonography,laparoscopy)
the amount of menstrual flow
the length of the menstrual cycle and menstrual period
the length and amount of episodes of intermenstrual bleeding
any episodes of contact bleeding.
the last menstrual period ， the last normal menstrual period
age at menarche and menopause
any changes in general health.
Abdominal masses and an enlarged ， irregular uterus suggest myoma.
A symmetrically enlarged uterus is more typical of adenomyosis or endometrial carcinoma.
Atrophic and inflammatory vulvar and vaginal lesions can be visualized
cervical polyps and invasive lesions of cervical carcinoma can be seen.
Rectovaginal examination is especially important sometimes
Cytologic examination -cytologic smears A very useful method to screen the asymptomatic intraepithelial lesions.
the Novak suction curet
the Duncan curet
the Kevorkisn curet
Ultrasound following injection of saline into the uterus has been used to evaluate the endometrial cavity for polyps ， fibroids ， or other abnormalities.
Hysteroscopy Placing an endoscopic camera through the cervix into the endometrial cavity allows direct visualization of the cavity.
Dilatation and curettage(D ＆ C)
D ＆ C is the gold standard for the diagnosis of abnormal uterine bleeding.
Curettage of the endocervix should be performed before sounding of the endometrial cavity or dilatation of the cervix is done.
Other diagnostic procedures
abnormal uterine bleeding due to gynecologic diseases and disorders
Vulva and vagina --atrophic vulvitis or vaginitis
Cervix – eversion, cervical polyps, cervical cancer
Abnormal bleeding due to nongynecologic diseases and disorders
Blood dyscrasias and coagulation abnormalities
Use anticoagulants or adrenal steroids
Dysfunctional uterine bleeding(DUB)
Dysfunctional uterine bleeding(DUB) is irregular, abnormal uterine bleeding with no demonstrable organic causes. That is not caused by a tumor, infection, or pregnancy. It may be occur during postmenarchal and perimenopausal periods in a woman's reproductive life.
Exclusion of pathologic causes of abnormal bleeding establishes the diagnosis of DUB
DUB occur in
before the menopause(50%)
Etiology of DUB:
1. disorders of
hypothalamus---pituitary ---ovary axis
immature of feedback regulation in young women
ovarian function failure in premenopause women
the effects of sex hormones
excessive physical exercise
have developing folliculi
no mature follicle
no corpus luteum
only have estrogen, but no progestin
breakthrough bleeding, spoting
pathologic Changes in the endometrium
Proliferative phase endometrium
Depends on the age of patient
Acute hemorrhage :high-dose estrogen given intravenously or injection (25mg conjugated estrogen every 4h)
Hemodynamically stable patients: take oral conjugated estrogen (2.5mg every 4-6h) or take oral contraceptives 3-4 times the usual dose.
★ Lower the dose every 3 days for 1/3 dose after the bleeding stoped and when have lowered to an usual dose, give medroxyprogesterone acetate (MPA)10mg once or twice a day for 10-14d
2.5mg / 6h 2.5mg / 8h 2.5mg / 12h 2.5mg / d Use to bleeding stoped 3d 3d 3d 1.25mg / d 10-14d medroxyprogesterone acetate 10-14d
Next 3-6 months give cycling theraphy
Except the pathologic causes is necessary
Hormonal management is the same as for adolescents
Oral contraceptives may be used as normally prescribed if the patient don’t desire for childbearing
Induce ovulation if necessary
More care should be given to excluding pathologic causes because of the possibility of endometrial cancer
Aspiration ,curettage,or both should clearly establish anovulatory or dyssynchronous cycles as the cause before hormonal therapy is started.
Recurrences of abnormal bleeding demand further evaluation
D ＆ C:temporarily stop bleeding
Conservative surgery: endometrial ablation or resection using diathermy ,thermal (ballon, microwave..etc.)or laser.
Hysterectomy :whose lifestyle is compromised by persistence of irregular bleeding,coexistent endometriosis, myoma, other disorders of pelvic
polycystic ovarian syndrome(PCOS)
In 1935, Stein and Leventhal published a paper on their findings in seven women with amenorrhea, hirsutism, obesity, and a characteristic polycystic appearance to their ovaries — one of the first descriptions of a complex phenotype today known as the polycystic ovary syndrome . The condition is now well recognized as having a major effect throughout life on the reproductive, metabolic, and cardiovascular health of affected women.
Menstrual dysfunction- oligomenorrhea or amenorrhea
Hyperandrogenism -hirsutism, acne, male pattern balding or hair loss
Ovarian Morphology- Polycystic ovaries be seen on ultrasonography
Obesity and insulin resistance -At least one-half of women with PCOS are obese and with insulin resistance
Excessive body hair. In women with PCOS dark, coarse hair will appear on the face, neck, chest, arms, and in between the legs.
Because women with PCOS are producing more male hormone, that produces more sebum ( skin oils and old tissue) and causes blocked pores and more acne around the jawline, arms and chest.
Alopecia or Female Pattern Baldness
This is caused by the increase of male hormone in the women's body. Thinning or loss of hair is usually contained to top of the scalp, but in severe cases loss of hair in front or on the hairline has been documented.
“ Dirty Skin” or Acanthosis Nigricans
This condition causes light brown to black rough patches around the neck and under arms.
but obesity increases severity therefore those worst affected are likely to be obese
Diagnostic Criteria of PCOS
after the exclusion of related disorders, by two of the following three features:
1) oligo- or anovulation;
2) clinical and/or biochemical signs of hyperandrogenism;
3) polycystic ovaries.
expert conference held in
Rotterdam in May 2003
Long term risks of PCOS
Type 2 diabetes
Mechanism of PCOS
Complicated and unclearly knowed
If pregnancy is desired ------ induce ovulation
anti-androgens (agents that lower
gonadotropin releasing hormone
If pregnancy is not desired
to reduce the risk of endometrial cancer ( birth control pills)