Florida International University BSC MISC OBGYN EOR 5

Menstruation (15%) – 7  GTPAL o Gravida o Term o Preterm o Abortion o Living Normal Physiology  Phase 1 – Follicular phase [proliferative phase] Days 1-14 o ESTROGEN predominates  Endometrium thickens = proliferation  GnRH   FSH & LH o Ovaries   FSH = follicle stimulating hormone  follicle & egg maturation   LH = stimulates follicle to produce estrogen o ESTROGEN Causes NEGATIVE FEEDBACK to HPO system Stops new follicles from maturing  OVULATION Days 12-14 o Switch from negative  positive feedback =  estrogen, FSH & LH o LH surge causes ovulation = egg release  Ruptured follicle becomes corpus luteum  Phase 2 – Luteal Phase [secretory phase] Days 14-28 o PROGESTERONE predominant  LH surge causes ruptured follicle to become corpus luteum  Corpus luteum secretes progesterone & estrogen to main endometrial lining  Negative feedback again o EGG FERTILIZED = pregnancy  Blastocyte [maturing zygote] keeps corpus luteum functional  Secreting progesterone & estrogen  keeps endometrial thick for implantation o Menstruation = 1st day of follicular phase EGG NOT FERTILIZED  Corpus luteum deteriorates  decline in progesterone & estrogen  endometrium sloughs off LT menstruation  Negative feedback switched to positive feedback   GnRH  CYCLE REPEATS  Dysfunctional [Abnormal] Uterine Bleeding o Abnormal frequency or intensity of menses due to nonorganic causes o Normal Cycle 24-38 days o Normal menstruation  4.5-8 days  Average loss 30 ml – 80 ml o Terms  Amenorrhea = Absence of period  Cryptomenorrhea = light flow or spotting  Menorrhagia = HEAVY or PROLONGED bleeding @ normal menstrual intervals  Metrorrhagia = irregular bleeding BETWEEN EXPECTED CYCLES  Menometrorrhagia = irregular, EXCESSIVE bleeding BETWEEN cycles  Oligomenorrhea = infrequent periods: prolonged cycles > 35 days but less < 6 months  Polymenorrhagia = frequent cycle intervals < 21 days o Etiology  Chronic anovulation – 90%  Disruption of hypothalamus-pituitary axis  Seen w/ extreme ages: teenagers soon after menarche & perimenopausal  UNOPPOSED ESTROGEN o Without ovulation = no progesterone = excess estrogen = endometrial growth o Irregular, unpredictable shedding/bleeding  Ovulatory – 10%  Regular cyclical shedding  + ovulation w/ prolonged progesterone section  increase blood loss & prostaglandins  menorrhagia o Diagnosis of Exclusion  No evidence of organic cause & negative pelvic exam  Workup  Hormone levels  Transvaginal US  Endometrial biopsy  if endometrium >4 mm on US or women >35 y/o  R/O endometrial carcinoma o Management  1 – control bleeding  Acute severe bleeding o High dose IV estrogens or high dose OCPs o D&C if IV estrogen fails  2 – prevent future bleeding  3 – minimize endometrial cancer risk  Anovulatory [90%] & Ovulatory [10%]  OCPs = 1st line  regulates periods & reduces flow; decreases endometrial CA risk  Progesterone IF estrogen is contraindicated  GnRH agonists – leuprolide  Surgery IF NOT responsive to medical tx  Hysterectomy = DEFINITIVE tx for DUB  Endometrial ablation – pts who DON’T want a hysterectomy  Amenorrhea o Absence of menses o Workup  Pregnancy test = MCC of secondary amenorrhea  Serum prolactin  FSH & LH  TSH o Primary Amenorrhea  Failure of menarche  by 15 w/ secondary sex characteristics  by 13 w/o secondary sex characteristics  Etiologies  Uterus Present & Breast Present o Outflow obstruction  Transvaginal septum = 2 compartment  Imperforated hymen = no opening into canal, blue bulge  Uterus Present – Breast ABSENT o Ovarian Causes  elevated FSH & LH  Premature ovarian failure – 46XX = early menopause  Gonadal dysgenesis = Turner’s 45XO o Normal/Low FSH & LH  Hypothalamus-Pituitary Failure  Puberty delays – athletes, illness, anorexia  Uterus ABSENT & Breast Present o Mullerian agenesis – 46 XX = absence of uterus, cervix, and/or vagina o Androgen insensitivity – 46 XY = genetically male  Uterus ABSENT & Breast ABSENT o RARE o Defect in testos