Dysfunctional Uterine Bleeding Infertility Peri-menopausal Period Syndrome

8/12/2019 Dysfunctional Uterine Bleeding Infertility Peri-menopausal Period Syndrome

1/60

1

Dysfunctional uterine bleeding

Infertility

Peri-menopausal period syndrome

Zhao aiminM.D., Ph.D., Pro fess orDepartment Of Obstetr ics & Gynecolog y

Renj i Hospita l Affi l ia ted to SJTU School of Medicine


2/60

2

Dysfunctional Uterine Bleeding

(DUB)


3/60

3

Definition

an abnormal uter ine bleeding without an

obvious organic abnormali ty (neoplasma,

pregnancy, inf lammation, trauma, blooddyscrasia,hormone adminstrationat el)

unnormal releasing of sex hormones


4/60

4

Anovulatory functional bleedingovulatory functional bleeding

DUB occur inbefore the menopause(50%)

after menarche(20%)

in reproductive times(30%)


5/60

5

Anovulatory functional bleeding


6/60

6

Etiologyof DUB:

1. disorders of

hypo thalamus ---pi tu i tary ---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


7/60

7

Pathology

Change in the endometrium

simple hyperplasia(Cystic hyperplasia , benign)

complex hyperplasia(Adenomatoushyperplasia ,precursor of carcinoma)

atypical hyperplasia(10%-25% carcinoma)

proliferative phase of endometrium (nosecretive change )

atrophic endometrium


8/60

8

Mechanisms

Anovulation ----

have developing folliculi

no mature follicle

no corpus luteum

only have estrogen, but no

progestin

breakthrough bleeding, spoting


9/60

9

Clinical presentation

Menorrhgia(Polymenorrheametrorrhgia

menometrorrhgia


10/60

10

Diagnosis

1.History

history of age of menarche,

initial regularity of cycle,

cycle length, amount, duration of flow,

contraceptive pill

abortion, ectopic pregnancy,

endometriosis,

pelvic inflammatory disease


11/60

11

hemorrhagic diseases,

endocrine deseases

traumas,

nutritional status

To decide :the dysfunctional bleeding or anatomic

abnormality


12/60

12

2.physical examinationpelvic vaginal examination (PV)

3.laboratory diagnosis bleed count, coagulation studies,

endocrine studies

curettage


13/60

13

Treatment

medicine treatment1.to stop 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 ovulationClomiphene, HMG, FSH,GnRH)


14/60

14

Curettagefor adults

rarely use for teenagers unless bleeding is

very severe)

aims

1.stop an acute severe bleeding quickly and

effectively

2.to prevent chronic recurrence of DUB

3.diagnosis


15/60

15

Hysterectomy: for older patient,

never been done in adolescent


16/60

16

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


17/60

17

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


18/60

18

treatment HCG (5000-10000U 14th day)

progestin(15th day X 10 days)

ovulation induction(Clomiphone, HMG, FSH,

mature follicle --- good corpus luteum)


19/60

19

2.Irregular shedding ofendometrium

pathology persistent corpus luteum

estrogen and progesterone

maintain to effect the

endometrium


20/60

20

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


21/60

21

Treatment progestin ( 5 days before next

menstruation, feedback)

ovulation induction


22/60

22

Peri-menopausal Period

Syndrome(Climacteric Syndrome)


23/60

23

Definition

Menopause the cessation of menses for a year or more.

It is caused by ovarian failure.

It marks the end of a womensreproductive life

It occurs normally between the ages of 4555

years and at a mean age of 51 years.

It is a physiological process

Peri-menopause is a period before and after themenopause.


24/60


25/60

25

Peri-menopausal Period Syndrome

peri-menopause accompanied by the symptoms

of climacteric, including hot flashes, excessive

perspiration, night sweats, depression, agitation,

vaginal dryness, insomnia

The basic causes of the climacteric syndrome

are a progressive decline in ovarian productionon estrogens and other sex hormones


26/60

26

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)


27/60

27

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


28/60

28

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.


29/60

29

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 urinary epithelium

decreased elastic of reproductive and urinary tract

supporting structures


30/60


31/60

31

2. Late symptoms and problems

6)osteoporosisAccelerated bone loss in women is clearly

related to the loss of ovarian function.

Studies show that a rapid decrease in bonemass occurs within 2 months of ovariotomy


32/60

32

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


33/60

33

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 estrogenmight be a key factor.

But recent data suggest that Estrogen has no suchprotection against heart disease


34/60

34

Diagnosis

1) Historymenstrual abnormality

2) Symptoms: vasomotor symptoms, vaginaldryness, urinary frequency, insomnia,irritability, anxiety, skin change, breastchanges, urinary tract problem, pelvic floorchange( cystocele. Rectocele. Prolapse), skeletal

change(backache, ) and so on.


35/60

35

3)Physical examination:

The clinical findings vary greatly depending on the timeelapsed since menopause and the severity of theestrogen deficiency

Skin: thin ,dry

Breast loss turgor

The labia are small

The uterus becomes much smaller

The muscles of the pelvic floor are looser and are thin

Prolapse may be present


36/60

36

4) Laboratory diagnosis

Cytologic smear from the vaginal wall

E2, FSH, LH determination

Radiography, X-ray densitometry


37/60

37

Treatment

1) education, understanding, reassurance

2) hormone replacement therapy(HRT)

Estrogen therapy The use of estrogens can rel ieve the menopausal

symptoms.

The hot f lashes , sweats and other complaints

disappear or improve within a few days ofstar ting estrogens therapy.


38/60

38

The adminis t rat ion of est rogen wi thout

progestogen increases the r isk of

endometr ial cancerand breast cancer.

So, co rrect cycl ical therapy, w ith 10 days

progestogen per month, can reduces the

incidence of cancer.


39/60

39

Contraindication

thrombo-embolish

hypertension

diabetes

chronic liver disease

myoma, endometriosis,

breast disease

gallbladder disease


40/60

40

3) traditional medicine therapy


41/60

41

Infertility


42/60

42

Definition

defined as not being able to get

pregnant despite trying for one to

two years.

10 percent of couples are affected

Primary infertility: never conceived

Secondary infertility: at least oneprevious pregnancy


43/60

43

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 tothe inside of the uterus.


44/60

44

Causes

The incidence of male factorsand female factor infertility aresimilar

Ovary factor 25% (anovulation)

Tubal and pelvic factor 25 Uterine factor


45/60

45

Ovulatory factor Ovulatory disfunction

Anovulatory

Amenorrhea

Investigated as follow by means ofMid-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


46/60

46

Anatomical factor:Tubal disease following pelvic

inflammatory disease(PID)

Endometriosis


47/60

47

Uterine factor:

Polyps

Submucosal myoma

Endometrial scarring

Cervical factors


48/60

48

Male factor:semen analysis

Volume 1.5-5.0ml

Count>20 million/ml. 40X106/total

Initial motility(30%

No clumping or significant WBC(


49/60

49

The step of test

The assessment of both partners should begin simultaneously

History

Physical examination

Ovulation detection(menstrual history,BBT,seriumprogester ine,ur inary LH ,ser ial ul trasound)

Evaluation of tubal function (Hysterosalpingogram, HSG,

Laparoscopy)

Evaluation of uterine cavity (HSG, Hysteroscopy) Cervical factor (postcoital testing, PCT)


50/60

50

Male infertility factor

unexplained infertility


51/60

51

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)


52/60


53/60

53

Assisted reproductive technology (ART)

uses special methods to help infertile couples.

ART involves handling both the woman's eggs andthe man's sperm.

Success rates vary and depend on many factors.

ART can be expensive and time-consuming. ButART has made it possible for many couples tohave children that otherwise would not have beenconceived.


54/60

54

Intrauterine insemination

Artificial insemination with husbands sperm(AIH)

Artificial insemination by donor (AID)


55/60

55

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 theyhave become fertilized by the sperm and are dividing into

cells.

these fertilized eggs (embryos) are then placed in thewoman's uterus


56/60

56

Gamete intrafallopian transfer

(GIFT):

is similar to IVF, but used when the

woman has at least one normalfallopian tube.

Three to five eggs are placed in the

fallopian tube, along with the man'ssperm, for fertilization inside the

woman's body.


57/60

57

Zygote intrafallopian transfer

(ZIFT),

ICSI (intracytoplasmic sperm

injection)


58/60

58

ART procedures sometimes involvethe 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 passedon to her baby.


59/60

59

Key Word

Infertility

Ovulation induction

ART

IVF

What are the causes of infertility?

Explaining the steps of infertility

test.

Th k f Y Att ti


60/60

Zhao aiminM.D., Ph.D., Pro fess orDepartment of Obstetr ics & Gyn ecology

Renj i Hospita l Aff i l iated to SJTU Schoo l of Medicine

Thanks for Your Attention

Documents

Dysfunctional Uterine Bleeding Infertility Peri-menopausal Period Syndrome