Our topics today
Uterine prolapse
Amenorrhea
Dysfunctional uterine bleeding
PCOS
Infertility
Peri-menopause period syndrome
2016/7/1
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 degree:cervix still inside vagina
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Degrees of uterine prolapse
Second degree:the cervix appears outside the
vulva. The cervical lips may become congested and
ulcerated
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Degrees of uterine prolapse
Third degree:complete 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

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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



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endometrial destruction (Asherman’s 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,
Turner’s 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(假孕)
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






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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
I°amenorrhae
↓
estrogen – progesterone therapy
↓
↓
menses (II°amenorrhae)
↓
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↓
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
↓
hypothalamus
amenorrhea
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↓
LH ,FSH low
↓
pituitary
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，
(LH:FSH≧3:1)
 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 women’s 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
menopause)
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after
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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(动脉硬化)
 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 factor<5%
 Cervical factor <5%
 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
 Count>20 million/ml. 40X106/total
 Initial motility(<1 hour)50%
 Normal Morphogy>30%
 No clumping or significant WBC(<1 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 husband’s 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



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Infertility
Ovulation induction
ART
IVF
What are the causes of infertility?
Explaining the steps of infertility
test.
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