NEUROENDOCRINAL NEUROENDOCRINAL REGULATION OF REGULATION OF

MENSTRUAL CYCLEMENSTRUAL CYCLE

AMAN BALOCHAMAN BALOCH

NEUROENDOCRINAL NEUROENDOCRINAL REGULATION OF MENSTRUAL REGULATION OF MENSTRUAL CYCLECYCLE – – is a complex, is a complex, genetically determined system of genetically determined system of inter-regulation of genitals, inter-regulation of genitals, central nervous system and central nervous system and target organs. target organs.

Formation of reproductive Formation of reproductive system starts antenatally and system starts antenatally and finishes at the age of 18-21.finishes at the age of 18-21.

5 LEVELS 5 LEVELS OF MENSTRUAL CYCLE OF MENSTRUAL CYCLE

REGULATION.REGULATION. 1 Target organs.1 Target organs. These include external and internal These include external and internal

genital organs, mammary glands, bone genital organs, mammary glands, bone tissue and skin.tissue and skin.

Target organs have receptors for steroid Target organs have receptors for steroid hormones.hormones.

Influence of sex hormones on these Influence of sex hormones on these organs leads to formation of secondary organs leads to formation of secondary sexual character, cyclical processes in sexual character, cyclical processes in endometrium and vagina.endometrium and vagina.

2. Ovaries.2. Ovaries. Steroid hormones in the ovary are Steroid hormones in the ovary are

synthesized due to the action pituitary synthesized due to the action pituitary hormones.hormones.

The hormones synthesis process inside the The hormones synthesis process inside the ovary is called steroidogenesis.ovary is called steroidogenesis.

Adrenal glands and adipose tissue Adrenal glands and adipose tissue synthesize steroid hormones too.synthesize steroid hormones too.

Steroid hormones are synthesized from Steroid hormones are synthesized from cholesterol and have the same nature.cholesterol and have the same nature.

Schematically this process can be Schematically this process can be represented in the following way: represented in the following way: cholesterol – pregnenolone – androgens – cholesterol – pregnenolone – androgens – estrogens.estrogens.

Ovaries synthesize 3 types of Ovaries synthesize 3 types of hormones:hormones: estrogens, gestogens, estrogens, gestogens, androgens. Female organism produces 3 androgens. Female organism produces 3 fractions of estrogens.fractions of estrogens.

EstradiolEstradiol - - is the most active estrogen and is the most active estrogen and is produced by ovaries.is produced by ovaries.

EstroneEstrone – – less active, mainly produced by less active, mainly produced by adipose tissue. adipose tissue.

EstriolEstriol – – is a result of transformation of is a result of transformation of estradiol, estrone and androgens of estradiol, estrone and androgens of epinephroses. epinephroses.

Estriol is produced only during pregnancy Estriol is produced only during pregnancy and has minimal hormonal activity.and has minimal hormonal activity.

Progesterone –Progesterone – is the hormone of is the hormone of yellow body of ovary and is a yellow body of ovary and is a gestogen.gestogen.

Major androgen of ovary is Major androgen of ovary is testosteronetestosterone, which is produced by , which is produced by cells of internal theca. Testosterone cells of internal theca. Testosterone is not very active.is not very active.

Under the influence of enzyme 5-α-Under the influence of enzyme 5-α-reductase, it is transformed into a reductase, it is transformed into a more active hormone – more active hormone – dehydrotestosterone.dehydrotestosterone.

Most estrogens and androgens merge Most estrogens and androgens merge with sex steroid-binding globulin with sex steroid-binding globulin (SSBG).(SSBG).

Smaller amount of estrogens merge Smaller amount of estrogens merge with albumin and erythrocytes.with albumin and erythrocytes.

Only one per cent of estrogens remains Only one per cent of estrogens remains free and influences the target organs. free and influences the target organs.

SSBG is synthesized by liver, its SSBG is synthesized by liver, its quantity is proportional to estrogen quantity is proportional to estrogen level, and decreases under the level, and decreases under the influence of androgens.influence of androgens.

Today have been discovered 2 Today have been discovered 2 progesterone-binding proteins.progesterone-binding proteins.

PHYSIOLOGIC EFFECTS OF PHYSIOLOGIC EFFECTS OF ESTROGENESTROGEN

ON FEMALE ORGANISM ON FEMALE ORGANISM Uterus. Uterus. Estrogens determine the Estrogens determine the

proliferation processes in endometrium, proliferation processes in endometrium, growth of myometrium and uterine tubes.growth of myometrium and uterine tubes.

Mammary glands. Mammary glands. Stimulate growth.Stimulate growth. Bone tissue. Bone tissue. Estrogens are Estrogens are

parathormone antagonists. They hinder parathormone antagonists. They hinder development of osteoporosis and development of osteoporosis and condense growth zones in bones.condense growth zones in bones.

Cardiovascular system - iCardiovascular system - increase the ncrease the arterial pressure and vascular tone.arterial pressure and vascular tone.

Circulatory system. Circulatory system. Increase the Increase the amount of fibrin.amount of fibrin.

Mineral metabolism. Mineral metabolism. Estrogens Estrogens influence the natrium metabolism they influence the natrium metabolism they attract sodium from tissues and can cause attract sodium from tissues and can cause oedemas.oedemas.

Lipidic metabolism. Lipidic metabolism. Increases quantity Increases quantity of high-density β-lipoproteins; this has of high-density β-lipoproteins; this has anti-atherosclerotic effect.anti-atherosclerotic effect.

Central nervous system. Central nervous system. Estrogens Estrogens form optimal neuropsychic condition. They form optimal neuropsychic condition. They change synthesis of pituitary and change synthesis of pituitary and hypothalamus hormone.hypothalamus hormone.

PHYSIOLOGIC EFFECTS OF PHYSIOLOGIC EFFECTS OF PROGESTERONE.PROGESTERONE.

Uterus. Uterus. In case of sufficient concentration of In case of sufficient concentration of estrogens, progesterone exerts influence upon estrogens, progesterone exerts influence upon tissues. tissues.

Progesterone creates the evident anti-Progesterone creates the evident anti-proliferative effect and conditions the proliferative effect and conditions the secretion processes in endometrium.secretion processes in endometrium.

Besides, progesterone furthers myometrium Besides, progesterone furthers myometrium growth.growth.

Mammary gland. Mammary gland. Along with estrogens and Along with estrogens and prolactin, progesterone conditions tissue prolactin, progesterone conditions tissue development. Progesterone also furthers development. Progesterone also furthers lactation.lactation.

Cardiovascular system. Cardiovascular system. Progesterone decreases vessels tone Progesterone decreases vessels tone and arterial pressure.and arterial pressure.

Circulatory system. Circulatory system. Progesterone Progesterone does not influence the amount of fibrin.does not influence the amount of fibrin.

Mineral metabolism. Mineral metabolism. Progesterone Progesterone has diuretic effect.has diuretic effect.

Central nervous system. Central nervous system. Progesterone may cause depressions. Progesterone may cause depressions. It shows evident anti-gonadotrophic It shows evident anti-gonadotrophic action.action.

EFFECTS OF EFFECTS OF ANDROGENS.ANDROGENS.

- Androgens in normal concentration are - Androgens in normal concentration are synergists of estrogens.synergists of estrogens.

- In high concentrations androgens show - In high concentrations androgens show evident anti-gonadotrophic action and evident anti-gonadotrophic action and further the development of secondary further the development of secondary male sexual characters.male sexual characters.

- During antenatal and postnatal periods - During antenatal and postnatal periods increase of their level causes change of increase of their level causes change of central nervous system.central nervous system.

3. Hypophysis.3. Hypophysis.

Hypophysis is divided into 2 lobes: Hypophysis is divided into 2 lobes: anterior – adenohypophysis and anterior – adenohypophysis and posterior – neurohypophysis.posterior – neurohypophysis.

Adenohypophysis consists of groups Adenohypophysis consists of groups of cells, these groups of cells are of cells, these groups of cells are responsible for the synthesis of the responsible for the synthesis of the following hormones:following hormones:

growth hormone (somatotropic growth hormone (somatotropic hormone – STH);hormone – STH);

thyrotropin (thyroid stimulating thyrotropin (thyroid stimulating hormone – TSH);hormone – TSH);

prolactin (PRL);prolactin (PRL); follicle-stimulating hormone (FSH);follicle-stimulating hormone (FSH); luteinizing hormone (LH);luteinizing hormone (LH); adrenocorticotropic hormone (ACTH);adrenocorticotropic hormone (ACTH); melanotropic hormone (MH).melanotropic hormone (MH).

LH, FSH, PRL are major hormones LH, FSH, PRL are major hormones which regulate menstrual cycle.which regulate menstrual cycle.

But it is only possible under the But it is only possible under the condition of optimal concentrations condition of optimal concentrations of other pituitary hormones.of other pituitary hormones.

Synthesis of pituitary hormones is Synthesis of pituitary hormones is realized due to stimulating impact of realized due to stimulating impact of hypothalamus.hypothalamus.

PRL synthesis depends on dopamine PRL synthesis depends on dopamine concentration.concentration.

PRL concentration increases when PRL concentration increases when dopamine level decreases.dopamine level decreases.

Hormones are not Hormones are not synthesized in the posterior synthesized in the posterior lobe of hypophysis.lobe of hypophysis.

Oxytocin and vasopressin are Oxytocin and vasopressin are synthesized in hypothalamus, synthesized in hypothalamus, but are accumulated in the but are accumulated in the posterior lobe of hypophysis.posterior lobe of hypophysis.

4. Hypothalamus.4. Hypothalamus. Nucleuses of hypothalamus Nucleuses of hypothalamus

synthesize the following synthesize the following neurohormones: libertines and neurohormones: libertines and statines.statines.

The libertines stimulate The libertines stimulate adenohypophysis, statines inhibit it.adenohypophysis, statines inhibit it.

These hormones are called These hormones are called releasing hormones.releasing hormones.

Libertines include the following Libertines include the following hormones:hormones:

adrenocorticotropin-releasing adrenocorticotropin-releasing hormone (ACTH-RG);hormone (ACTH-RG);

thyrotropin-releasing hormone (TRG);thyrotropin-releasing hormone (TRG); gonadotropin-releasing hormone (GN-gonadotropin-releasing hormone (GN-

RG);RG); growth hormone-releasing hormone growth hormone-releasing hormone

(somatoliberin GH-RG);(somatoliberin GH-RG); melanoliberin (M-RG)/melanoliberin (M-RG)/

Statines Statines include the include the following hormones:following hormones:

somatostatin;somatostatin; dopamine (major prolactin-dopamine (major prolactin-

inhibiting factor).inhibiting factor).

Neurohormones are synthesized not Neurohormones are synthesized not only in hypothalamus.only in hypothalamus.

Somatostatin is synthesized in Somatostatin is synthesized in tissues of thyroid gland, bowels.tissues of thyroid gland, bowels.

Other hypothalamus peptides – Other hypothalamus peptides – gastrin, cholecystokinin, enkephaline gastrin, cholecystokinin, enkephaline are synthesized by other tissues also.are synthesized by other tissues also.

They create a regulation system They create a regulation system called “diffused neuroendocrinal called “diffused neuroendocrinal system of organism”.system of organism”.

5. Extra-hypothalamic 5. Extra-hypothalamic structures.structures.

Epiphysis, limbic system, celebrum Epiphysis, limbic system, celebrum tonsil and hippocampus influence tonsil and hippocampus influence the reproductive function.the reproductive function.

They are related to extra-They are related to extra-hypothalamic structures.hypothalamic structures.

Function of hypothalamus can be Function of hypothalamus can be stimulated or inhibited by stimulated or inhibited by enkephalins, endorphins, enkephalins, endorphins, neuropeptides.neuropeptides.

NEUROENDOCRINAL NEUROENDOCRINAL REGULATION REGULATION

OF MENSTRUAL CYCLE.OF MENSTRUAL CYCLE. At the age of 10-12 years the reproductive At the age of 10-12 years the reproductive

system starts its development.There are system starts its development.There are several theories, which explain activation several theories, which explain activation of hypothalamo-pituitary-ovarian system.of hypothalamo-pituitary-ovarian system.

1.Theory of late-pubescence. According to 1.Theory of late-pubescence. According to this theory sensitivity of hypothalamus to this theory sensitivity of hypothalamus to the steroid hormones changes with the the steroid hormones changes with the age. Besides, sensitivity of ovaries to age. Besides, sensitivity of ovaries to gonadotropin increases also.gonadotropin increases also.

2.Theory of resonance. According 2.Theory of resonance. According to this theory the increase in to this theory the increase in electrical activity of hypothalamus electrical activity of hypothalamus nucleuses stimulates an increase nucleuses stimulates an increase of GN-RG level.of GN-RG level.

3.Theory of block release. 3.Theory of block release. According to this theory at the According to this theory at the start of pubescence epiphysial start of pubescence epiphysial function decreases and function decreases and hypothalamic function increases.hypothalamic function increases.

The activation of hypothalamus The activation of hypothalamus makes it oversensitive to decrease in makes it oversensitive to decrease in estrogen concentration.estrogen concentration.

Next, it synthesizes GN-RG, which Next, it synthesizes GN-RG, which stimulates production of FSH and LH.stimulates production of FSH and LH.

Gonadotropins influence the process Gonadotropins influence the process of growth and development of follicle of growth and development of follicle (“folliculogenesis”) in ovaries.(“folliculogenesis”) in ovaries.

This descending process is called This descending process is called direct relationship.direct relationship.

The ovary of a newborn girl contains The ovary of a newborn girl contains from 400.000 to 500.000 primary from 400.000 to 500.000 primary ovarian follicles.ovarian follicles.

Only 400 follicles ripen and reach the Only 400 follicles ripen and reach the ovulation.ovulation.

Under the influence of FSH the Under the influence of FSH the development of several primari development of several primari ovarian follicles starts in the ovary. ovarian follicles starts in the ovary.

In the beginning they grow In the beginning they grow independently.independently.

Later on, their growth depends on the FSH Later on, their growth depends on the FSH level and the sensitivity of follicle to the level and the sensitivity of follicle to the FSH.FSH.

Therefore, only one follicle reaches the Therefore, only one follicle reaches the size of pre-ovulatory, others atrophy.size of pre-ovulatory, others atrophy.

The wall of antrum-containing follicle has 3 The wall of antrum-containing follicle has 3 sheaths: interstitial, internal theca and sheaths: interstitial, internal theca and granulosis.granulosis.

These sheaths have different sensitivity to These sheaths have different sensitivity to gonadotrophic hormones.gonadotrophic hormones.

Intersticium and theca are more sensitive Intersticium and theca are more sensitive to LH; granulosis is more sensitive to FSH.to LH; granulosis is more sensitive to FSH.

Follicle synthesizes steroid hormones. Follicle synthesizes steroid hormones. This process is called steroidogenesis.This process is called steroidogenesis. Theca and intersticium synthesize Theca and intersticium synthesize

steroids up to androgen fraction; steroids up to androgen fraction; granulosis produces estrogens.granulosis produces estrogens.

Increase in estrogen concentration Increase in estrogen concentration depresses the function of hypophysis.depresses the function of hypophysis.

This process is called negative This process is called negative inverse relationship.inverse relationship.

It takes place in the early pubertal period It takes place in the early pubertal period when menstrual cycles are monophase.when menstrual cycles are monophase.

Positive inverse relationship is Positive inverse relationship is

characterized by maximum estrogen characterized by maximum estrogen concentration.concentration.

Consequently honadotropines and Consequently honadotropines and libertines increase dramatically.libertines increase dramatically.

Ovulation follows this process.Ovulation follows this process. The ovulation process is a histochemical The ovulation process is a histochemical

process.process. Estrogens, prostaglandins and histamine Estrogens, prostaglandins and histamine

influence the sheath of the follicle and influence the sheath of the follicle and cause its rupture.cause its rupture.

Granulosis cells are transformed into Granulosis cells are transformed into the yellow body under the influence the yellow body under the influence of LH after ovulation.of LH after ovulation.

The yellow body synthesizes The yellow body synthesizes progesterone.progesterone.

Increase of progesterone inhibits the Increase of progesterone inhibits the synthesis of LH.synthesis of LH.

This causes the death of the yellow This causes the death of the yellow body. body.

The ovarian cycle is The ovarian cycle is a consistent process a consistent process of growth and development of follicle, of growth and development of follicle, ovulation, development and death of the ovulation, development and death of the yellow body.yellow body.

Ovarian cycle is divided into 3 phases:Ovarian cycle is divided into 3 phases: Follicular phaseFollicular phase is characterized by is characterized by

growth and development of follicle.growth and development of follicle. It lasts 12-14 days.It lasts 12-14 days. Ovulatory phaseOvulatory phase – lasts several hours. – lasts several hours. Lutein phaseLutein phase is characterized by is characterized by

development and functioning of the yellow development and functioning of the yellow body.body.

Uterine cycle is Uterine cycle is a cyclic process in the a cyclic process in the ovary, which causes cyclic changes in the ovary, which causes cyclic changes in the endometrium. It has 4 phases:endometrium. It has 4 phases:

Desquamation. Desquamation. Decrease of steroid Decrease of steroid hormones causes spasm, ischemia and hormones causes spasm, ischemia and rejection spiroid artery of decidual sphere of rejection spiroid artery of decidual sphere of endometrium.endometrium.

First day of desquamation corresponds to the First day of desquamation corresponds to the first day of menstruation and menstrual first day of menstruation and menstrual cycle.cycle.

Regeneration. Regeneration. It corresponds to the early It corresponds to the early period of follicular phase in the ovary.period of follicular phase in the ovary.

Regeneration lasts 4-5 days.Regeneration lasts 4-5 days. It starts with epithelization of endometrium.It starts with epithelization of endometrium.

Proliferation. Proliferation. It lasts 5-7 days and results It lasts 5-7 days and results in ovulation.in ovulation.

It corresponds to the late period of It corresponds to the late period of follicular phase in the ovary.follicular phase in the ovary.

Is characterized by proliferation of Is characterized by proliferation of epithelium and development of spiroid epithelium and development of spiroid arteries.arteries.

Secretion. Secretion. It corresponds to lutein phase It corresponds to lutein phase in the ovary. It lasts 10-12 days. in the ovary. It lasts 10-12 days.

The process of proliferation is superseded The process of proliferation is superseded by secretion.by secretion.

If pregnancy did not take place, cyclic If pregnancy did not take place, cyclic processes in the system uterus-ovaries-processes in the system uterus-ovaries-hypothalamic-pituitary system repeat.hypothalamic-pituitary system repeat.

MENSTRUAL DISORDERSMENSTRUAL DISORDERS ETIOLOGYETIOLOGY Nervous diseases.Nervous diseases. Mental diseases.Mental diseases. Malnutrition.Malnutrition. Some occupational hazards.Some occupational hazards. Systemic and gynecologic inflammatory diseases.Systemic and gynecologic inflammatory diseases. Illness of the haemopoiesis, cardiovascular and Illness of the haemopoiesis, cardiovascular and

other systems.other systems. Gynecologic operations.Gynecologic operations. Puberty disorders.Puberty disorders. Age-specific reconstruction of the functional state Age-specific reconstruction of the functional state

in hypothalamic-pituitary-ovarian axis in the in hypothalamic-pituitary-ovarian axis in the menopause.menopause.

AMENORRHOEAAMENORRHOEA Pathological primary amenorrhoea – Pathological primary amenorrhoea –

when the patient has never menstruated.when the patient has never menstruated. Pathological secondary amenorrhoea – Pathological secondary amenorrhoea –

when the periods are absent for more when the periods are absent for more than 6 months.than 6 months.

Physiological amenorrhoea – before Physiological amenorrhoea – before puberty, during pregnancy and lactation, puberty, during pregnancy and lactation, and after the menopause.and after the menopause.

False amenorrhoea – when the flow does False amenorrhoea – when the flow does not escape because of some obstruction.not escape because of some obstruction.

True amenorrhoea – when the True amenorrhoea – when the endometrial cycle is absent.endometrial cycle is absent.

TRUE PATHOLOGICAL TRUE PATHOLOGICAL AMENORRHOEAAMENORRHOEA

1.Uterine disorders.1.Uterine disorders. the uterus may be congenitally the uterus may be congenitally

defective;defective; the endometrium atrophies after the endometrium atrophies after

irradiation with X-ray or radium, irradiation with X-ray or radium, and hysterectomy.and hysterectomy.

2. Ovarian disorders.2. Ovarian disorders. failure of ovarian development occurs in cases of failure of ovarian development occurs in cases of

gonadal dysgenesis;gonadal dysgenesis; Stein-LeventhalStein-Leventhal syndrome is a disorder of syndrome is a disorder of

unknown cause.unknown cause. After some years of normal menstruation After some years of normal menstruation

amenorrhoea occurs with hirsuties.amenorrhoea occurs with hirsuties. Both ovaries are enlarged and contain Both ovaries are enlarged and contain

multiple small follicular cysts.multiple small follicular cysts. There is a block in the normal conversion of There is a block in the normal conversion of

progesterone to estrogen so that an progesterone to estrogen so that an intermediate androgen substance intermediate androgen substance androstendione appears in excess.androstendione appears in excess.

The urinary excretion of estrogens is normal The urinary excretion of estrogens is normal or low, while that of pregnantriol (a metabolic or low, while that of pregnantriol (a metabolic product of certain androgens) is raised;product of certain androgens) is raised;

arrhenoblastoma is a very rare cause of arrhenoblastoma is a very rare cause of amenorrhoea;amenorrhoea;

ovarian infections or new growths as processes ovarian infections or new growths as processes destroying all ovarian tissue.destroying all ovarian tissue.

3. Pituitary disorders.3. Pituitary disorders. There is of production of gonadotrophic There is of production of gonadotrophic

hormones.hormones. Amenorrhoea is one aspect of general Amenorrhoea is one aspect of general

disorders and the gynecologist is seldom disorders and the gynecologist is seldom responsible for treatment.responsible for treatment.

Pituitary infantilism (Levi-Loraine Pituitary infantilism (Levi-Loraine syndrome). The adult resembles a child. syndrome). The adult resembles a child. No effective treatment is known.No effective treatment is known.

Pituitary cachexia (Simmond’s disease). Pituitary cachexia (Simmond’s disease). This is usually due to ischemic necrosis of This is usually due to ischemic necrosis of the pituitary glands (hypophysis) due to the pituitary glands (hypophysis) due to thrombosis of pituitary vessels after thrombosis of pituitary vessels after postpartum hemorrhage and collapse.postpartum hemorrhage and collapse.

Failure of lactation is followed by Failure of lactation is followed by genital atrophy, loss of pubic hair, genital atrophy, loss of pubic hair, weakness, anorexia.weakness, anorexia.

Treatment with cortisone, thyroxin and Treatment with cortisone, thyroxin and anabolic steroids may cause some anabolic steroids may cause some improvement.improvement.

Adipogenital dystrophy is characterized by Adipogenital dystrophy is characterized by dwarfing, adiposity and genital infantilism, and dwarfing, adiposity and genital infantilism, and is usually caused by a craniopharyngioma that is usually caused by a craniopharyngioma that involves the pituitary gland and involves the pituitary gland and hypothalamus. The treatment is surgical.hypothalamus. The treatment is surgical.

In acromegaly the eosinophilic adenoma of the In acromegaly the eosinophilic adenoma of the pituitary gland may destroy the gonadotrophic pituitary gland may destroy the gonadotrophic cells, and the same may happen with other cells, and the same may happen with other pituitary tumors.pituitary tumors.

Small pituitary adenoma may secrete prolactin Small pituitary adenoma may secrete prolactin and cause amenorrhoea with galactorrhoea.and cause amenorrhoea with galactorrhoea.

4.Other endocrine disorders.4.Other endocrine disorders. Amenorrhoea occurs:Amenorrhoea occurs: in severe cases of in severe cases of

hyperthyreoidism, myxoedema and hyperthyreoidism, myxoedema and cretinism;cretinism;

in some cases of diabetes;in some cases of diabetes; in Addison’s disease;in Addison’s disease; with adrenocortical tumors or with adrenocortical tumors or

hyperplasia.hyperplasia.

5. Nervous disorders5. Nervous disorders (stress or hypothalamic (stress or hypothalamic amenorrhoea). This is the amenorrhoea). This is the commonest type of commonest type of secondary amenorrhoea, secondary amenorrhoea, and may be the result of and may be the result of emotional disturbances.emotional disturbances.

6.Disorders of general health 6.Disorders of general health and nutrition.and nutrition. Any chronic or Any chronic or severe illness (including nutritional severe illness (including nutritional deficiency) will cause amenorrhoea.deficiency) will cause amenorrhoea.

7.Oral contraception.7.Oral contraception. A delayed A delayed first period is common after first period is common after stopping oral contraception. More stopping oral contraception. More prolonged amenorrhoea sometimes prolonged amenorrhoea sometimes occurs.occurs.

DIAGNOSISDIAGNOSIS General examination;General examination; Special gynecologic Special gynecologic

examination;examination; Ultrasonic;Ultrasonic; X-ray;X-ray; Hormonal tests.Hormonal tests.

TREATMENTTREATMENT Sedative therapy;Sedative therapy; Vitamin therapy;Vitamin therapy; Adequate nutrition, a special diet intended Adequate nutrition, a special diet intended

to decrease the body weight;to decrease the body weight; Physiotherapy (endonasal electrophoresis Physiotherapy (endonasal electrophoresis

with 2% solution of vitamin B1, 0.25% with 2% solution of vitamin B1, 0.25% solution of dyphenhydramine solution of dyphenhydramine hydrochloride).hydrochloride).

Drugs suppressing prolactin secretion Drugs suppressing prolactin secretion (bromocriptine, parlodel, dostineks).(bromocriptine, parlodel, dostineks).

Hormonal therapy of the cyclic hormones Hormonal therapy of the cyclic hormones (estrogens followed by progesterone).(estrogens followed by progesterone).

DISFUNCTIONAL UTERINE DISFUNCTIONAL UTERINE BLEEDINGBLEEDING

Disfunctional, or anovulatory Disfunctional, or anovulatory uterine bleeding is associated uterine bleeding is associated with anovulation caused by with anovulation caused by impaired or unestablished impaired or unestablished functional relationships in the functional relationships in the hypothalamic-pituitary-hypothalamic-pituitary-ovarian axis.ovarian axis.

ClassificationClassification

In juvenile age;In juvenile age; In reproductive age;In reproductive age; In the premenopausal In the premenopausal

period.period.

Dysfunctional uterine Dysfunctional uterine bleedings may be bleedings may be divided into anovulatory divided into anovulatory and ovulatory ones.and ovulatory ones.

Anovulatory bleedings are induced Anovulatory bleedings are induced by the absence of ovulation and by the absence of ovulation and luteal phase of the cycle.luteal phase of the cycle.

Anovulatory uterine bleeding Anovulatory uterine bleeding develops in patients with:develops in patients with:

persistence of an ovarian follicle; persistence of an ovarian follicle; persistent follicles release a large persistent follicles release a large number of estrogens;number of estrogens;

atresia of a few follicles; atresia of atresia of a few follicles; atresia of some small follicles is associated some small follicles is associated with hypoestrogenism.with hypoestrogenism.

Both account for continuous, monotonous Both account for continuous, monotonous secretion of estrogens.secretion of estrogens.

Ovulation does not occur and the corpus Ovulation does not occur and the corpus luteum fails to form.luteum fails to form.

Excessive proliferation of the endometrium Excessive proliferation of the endometrium occurs as a result of prolonged occurs as a result of prolonged exposure to estrogens in both processes. exposure to estrogens in both processes.

Persistent and atretic follicles undergo Persistent and atretic follicles undergo involution.involution.

The level of hormones (estrogens) is The level of hormones (estrogens) is decreased in the blood, and bleeding decreased in the blood, and bleeding develops. develops.

Circulation in the endometrium is Circulation in the endometrium is impaired, the capillary permeability impaired, the capillary permeability is decreased, and the sites of is decreased, and the sites of dystrophy and necrosis are dystrophy and necrosis are manifested.manifested.

The necrotic mucosa is rejected The necrotic mucosa is rejected slowly, which causes prolonged slowly, which causes prolonged bleeding. bleeding.

Dysfunctional uterine bleedings are Dysfunctional uterine bleedings are not attended with pain.not attended with pain.

CLINICAL PICTURECLINICAL PICTURE Amenorrhoea: in 4-8 weeks in persistent Amenorrhoea: in 4-8 weeks in persistent

follicle; 3-4 months in atretic follicles;follicle; 3-4 months in atretic follicles; Bleedings are more abundant in persistent Bleedings are more abundant in persistent

follicles, being occasionally profuse;follicles, being occasionally profuse; Anemia;Anemia; Decrease the patient’s working capacity;Decrease the patient’s working capacity; General fatigue;General fatigue; Headache;Headache; Poor appetite;Poor appetite; Sleep;Sleep; Pale skin;Pale skin; Tachycardia;Tachycardia; Decreased blood pressure.Decreased blood pressure.

DIAGNOSISDIAGNOSIS

Diagnosis is based on general and Diagnosis is based on general and gynecologic examination. At general gynecologic examination. At general examination one should pay examination one should pay attention to the typical sings:attention to the typical sings:

bleedings that follow the suppression bleedings that follow the suppression of menses;of menses;

monophase basal body temperature;monophase basal body temperature; high or low karyopycnotic index.high or low karyopycnotic index.

Dysfunctional uterine bleedings Dysfunctional uterine bleedings should be differentiated from many should be differentiated from many disease forms that are attended with disease forms that are attended with bleedings:bleedings:

abortions;abortions; interrupted fallopian pregnancy;interrupted fallopian pregnancy; tumors of the uterus.tumors of the uterus.

TREATMENTTREATMENT The doctor’s tactics largely The doctor’s tactics largely

depend on the patient’s depend on the patient’s age.age.

Juvenile bleedings.Juvenile bleedings. Conservative treatment (use Conservative treatment (use

coagulants, hemostatic agents, coagulants, hemostatic agents, stimulants of uterine contractility).stimulants of uterine contractility).

Hormonal haemostasis Hormonal haemostasis (“medicamentous curettage” synthetic (“medicamentous curettage” synthetic estrogen-progesteron drugs (logest, estrogen-progesteron drugs (logest, yrina, dgaz, ganin) are prescribed in a yrina, dgaz, ganin) are prescribed in a dose of 5-6 tablets daily is gradually dose of 5-6 tablets daily is gradually decreased to 1 tablet per day ( the total decreased to 1 tablet per day ( the total couse of drug administration is 21 couse of drug administration is 21 days). days).

Diagnostic curettage of the uterine Diagnostic curettage of the uterine mucosa.mucosa.

When bleeding has been arrested, When bleeding has been arrested, cyclic hormone therapy is administered cyclic hormone therapy is administered for 6 or 9 cycles.for 6 or 9 cycles.

In the child-bearing age.In the child-bearing age. Diagnostic curettage of the uterine Diagnostic curettage of the uterine

mucosa.mucosa. Conservative treatment.Conservative treatment. Hormonal haemostasis (“medicamen-tous Hormonal haemostasis (“medicamen-tous

curettage” synthetic progestins (norcolut, curettage” synthetic progestins (norcolut, orgametril, utrogestan, dyphaston) are orgametril, utrogestan, dyphaston) are prescribed in a dose of 5-6 tablets daily is prescribed in a dose of 5-6 tablets daily is gradually decreased to 1 tablet per day gradually decreased to 1 tablet per day ( the total couse of drug administration is ( the total couse of drug administration is 21 days). 21 days).

When bleeding has been arrested, cyclic When bleeding has been arrested, cyclic hormone therapy is administered for 6 or 9 hormone therapy is administered for 6 or 9 cycles. cycles.

Premenopausal and Premenopausal and menopausal agemenopausal age

Diagnostic curettage of the uterine Diagnostic curettage of the uterine mucosa.mucosa.

Conservative treatment.Conservative treatment. Hormonal haemostasis (“medicamen-Hormonal haemostasis (“medicamen-

tous curettage” synthetic progestins tous curettage” synthetic progestins (norcolut, orgametril, utrogestan, (norcolut, orgametril, utrogestan, dyphaston) are prescribed in a dose of dyphaston) are prescribed in a dose of 5-6 tablets daily is gradually decreased 5-6 tablets daily is gradually decreased to 1 tablet per day ( the total couse of to 1 tablet per day ( the total couse of drug administration is 21 days).drug administration is 21 days).

The therapy is directed at regulating The therapy is directed at regulating the menstrual function ( in women the menstrual function ( in women under 45 years) or its suppression ( in under 45 years) or its suppression ( in women over 45 years).women over 45 years).

DYSMENORRHOEA DYSMENORRHOEA (ALGOMENORRHOEA)(ALGOMENORRHOEA)

This term is used to painful This term is used to painful menstruation.menstruation.

Pain may develop before the Pain may develop before the onset of menstruation and onset of menstruation and continue throughout the continue throughout the period of menstrual flow.period of menstrual flow.

Sometimes, pain is severe and Sometimes, pain is severe and attended by nausea, vomiting and attended by nausea, vomiting and other disturbances, which reduce the other disturbances, which reduce the patient’s working capacity.patient’s working capacity.

In many cases dysmenorrhoea is just In many cases dysmenorrhoea is just a manifestation of systemic diseases. a manifestation of systemic diseases.

It may be attributed to retroflexion or It may be attributed to retroflexion or anteflexion of the uterus, cicatricial anteflexion of the uterus, cicatricial changes, and narrowing of the changes, and narrowing of the cervical canal.cervical canal.

Primary and secondary forms of Primary and secondary forms of dysmenorrhoea are distinguished.dysmenorrhoea are distinguished.

The formes does not appear to be The formes does not appear to be linked to any organic disease and is linked to any organic disease and is congenital.congenital.

The latter develops in women with The latter develops in women with previously normal menstruations.previously normal menstruations.

Secondary dysmenorrhoea may be Secondary dysmenorrhoea may be related to inflammatory processes, related to inflammatory processes, endometriosis, and genital tumors.endometriosis, and genital tumors.

Treatment.Treatment.

Anti-inflammatory drugs.Anti-inflammatory drugs. Hormonal drugs.Hormonal drugs. Surgical treatment.Surgical treatment. Sedative drugs.Sedative drugs. Vitamin therapy.Vitamin therapy.