“Approved”
on the meeting of methodical board
Department of Obstetrics and Gynaecology
with the Course of Infantile and Juvenile Gynaecology
dated “__”_________ 20__, minutes № __
Deputy Chief, DMS ___________ professor O.A.Andriiets
Methodological Instructions №6
to organize independent student’s work on the topic:
“Abnormalities in menstrual function in girls”
Subject:
Infantile
and
Juvenile
Gynaecology
Year: VI
Faculty: Medical
Number of hours: 2
Methodical instructions compiled by:
assistant lecturer Rak L.M.
I. Topic: Abnormalities in menstrual function in girls
II. Class duration – 4 hours.
III. Educational objectives:
The student must know:
1.
Classification of abnormalities in menstrual cycle.
2.
Pathogenesis of abnormalities of menstrual cycle.
3.
Indications to physiotherapeutic and sanatoria and health methods of
treatment of this pathology.
4.
Justify symptomatic and pathogenetic treatment of different kinds of
abnormalities of menstrual cycle.
5.
Justify indications to surgical methods of treatment.
The student must be able to:

Make a scheme of non-hormonal, hormonal hemostasis in abnormalities
of menstrual cycle in juvenile.

Prescribe medicine.
IV. Advice to the student.
Functional components of menstruation
 hypothalamus,
 pituitary,
 ovary,
 outflow tract,
 feedback mechanism
Primary amenorrhea is defined as the absence of menses by 16 years of age in
the presence of normal secondary sexual characteristics, or by 14 years of age
when there is no visible secondary sexual characteristic development.
Secondary amenorrhea - absence of menses for 6 months in a previously
menstruating female
Amenorrhea
1. Genuine & false
2. Primary & secondary
3. Physiological & pathological
4. The hypothalamic amenorrhea,
The pituitary amenorrhea,
The ovarian amenorrhea,
The uterine form of amenorrhea.
The hypothalamic amenorrhea
 Psychogenic amenorrhea
 Amenorrhea during falls pregnancy
 Amenorrhea as a symptom of nervous anorexia
 Amenorrhea as a symptom of adiposogenital dystrophy
 Amenorrhea as a symptom of the Lorence-Moon-Barde-Bidle syndrome
 Amenorrhea as a symptom of the Morghani_Stuart syndrome
 Amenorrhea as a symptom of the persistent lactation syndrome (the KiariFromel syndrome)
Psychogenic amenorrhea
 Appears as a result of stress situation or psychic traumas
 Excessive production of corticotropin within stress blocs production of
releasing hormones by Hypotalamus.
 Treatment:
– psychotherapy,
– sedative remedies,
– physiotherapy.
– After 2-3 months of treatment without result we prescribe thyroidin.
Amenorrhea during falls pregnancy
 Appears in women, who are eager or very afraid to become pregnant.
 Clinical features:
– Nausea
– Morning vomiting
– Swelling of breast
– Some enlarging & softening of uterus can appear
But all test for pregnancy are negative.
Anorexia Nervosa
 Onset between ages 10 and 30.
 Weight loss of 25% or weight 15% below normal for age and height.
Special attitudes:
 —Denial,
 —Distorted body image,
 —Unusual hoarding or handling of food.
At least one of the following:
 —Lanugo,
 —Bradycardia,
 —Overactivity,
 —Episodes of overeating (bulimia),
 —Vomiting, which may be self-induced
 Amenorrhea.
 No known medical illness.
 No other psychiatric disorder.
 Other characteristics:
 —Constipation,
 —Low blood pressure,
 —Hypercarotenemia,
 —Diabetes insipidus.
Anorexia Nervosa
 Cessation of menstrual cycle via endurance activities, inadequate body
weight, eating disorder, stress
 Reestablish normal hormone levels via diet and exercise counseling,
hormone therapy
Amenorrhea as a symptom of adiposogenital dystrophy
 It is usually associated with tumours of the hypothalamus, causing increased
appetite and depressed secretion of gonadotropin. It seems to affect males
mostly.
Is a condition characterized by
 Feminine obesity
 Growth retardation and retarded sexual development, atrophy or hypoplasia
of the gonads, and altered secondary sex characteristics,
 headaches
 mental retardation, problems with vision
 polyuria, polydipsia.
tumours of the hypothalamus
Amenorrhea as a symptom of the Laurence-Moon-Barde-Bidle syndrome
Laurence-Moon syndrome comprises
 Onset in childhood.
 Inheritance is autosomal recessive.
 retinitis pigmentosa, initially, problem of night vision; then central vision
and then peripheral vision loss progressing to blindness.
 mental retardation,
 stunted stature
 hypogonadism.
 Spinocerebellar ataxia and progressive spastic paraplegia
 The complete syndrome is seldom observed in the same individual, but the
features are often scattered among the siblings of one family or generation.
Members of these families have an increased number of miscarriages and
early deaths.
Amenorrhea as a symptom of the Morghani-Stuart syndrome
The main features of this hereditary syndrome are:
 1) hyperostosis frontalis interna,
 2) adipositas,
 3) virilism and hirsutism
 4) menstrual disorders
Treatment is symptomatic
Hyperprolactinemia has such causes:
 prolactin-secreting pituitary adenomas
 -other pituitary or hypothalamic tumors that may distort the portal
circulation and thereby prevent effective delivery of hypothalamic dopamine
(the putative prolactin inhibitory factor or hormone)
 -a variety of drugs that lower dopamine levels or inhibit dopamine action
(amphetamines, benzodiazepines, butyrophenones, metoclopramide,
methyldopa,
opiates,
phenothiazines,
reserpine,
and
tricyclic
antidepressants)
 -breast or chest wall surgery, cervical spine lesions, or herpes zoster
(activation of the afferent sensory neural pathway that stimulates prolactin
secretion, in a manner similar to suckling)
 -hypothyroidism (increased hypothalamic thyrotropin-releasing hormone
stimulates pituitary prolactin secretion directly)
 -pharmacologic estrogens (OCP)
 -other rare, nonpituitary sources (lung and renal tumors) or causes of
decreased prolactin clearance (renal failure).
The pituitary amenorrhea
Amenorrhea
in
case
of
pituitary nanism
 Disease develops in prenatal period or during the first months of life due to
infectious diseases or traumatic damages of anterior part of pituitary.
Insufficiency of all its hormones including somatotropin appears as a result.
 Treatment mainly is in an endocrinologist competence. One should begin
treatment in childhood with grows stimulation. Further replacement
hormonal therapy is indicated
Amenorrhea in case of gigantism and acromegalia
 Diseases are caused by Somatotropin hyperprodaction, production of
gonadothropic hormones is decreased. Amenorrhea has a secondary
character.
 Treatment. At pituitary tumors rhoentgenotherapy is indicated. For Patients
with gigantism estrogen therapy for stopping of excessive growth is
prescribed.
Itsenko-Cushing syndrome
Clinical features are:
 fatigue,
 weakness,
 abdominal obesity,
 «buffalo hump» (an excessive deposit of fat over the clavicles and back of
the neck),
 moon-shaped face,
 nervousness,
 irritability,
 depression,
 amenorrhoea or menstrual irregularity.
 Most commonly observed in females in childbearing age.
Clinical features are:
 fatigue,
 weakness,
 abdominal obesity,
 «buffalo hump» (an excessive deposit of fat over the clavicles and back of
the neck),
 moon-shaped face,
 nervousness,
 irritability,
 depression,
 amenorrhoea or menstrual irregularity.
 Most commonly observed in females in childbearing age.
Sheehan's Syndrome
 Acute infarction and necrosis of the pituitary gland due to postpartum
hemorrhage and shock is known as Sheehan's syndrome.
 The symptoms of hypopituitarism are usually seen early in the postpartum
period, especially failure of lactation and loss of pubic and axillary hair.
 Deficiencies in growth hormone and gonadotropins are most common,
followed by ACTH, and last, by TSH in frequency. Diabetes insipidus is not
usually present. This can be a life-threatening condition, but fortunately,
because of good obstetrical care, this syndrome is never encountered by
most of us.
The ovarian amenorrhea
 The Shereshevsky-Terner’s syndrome
 The Stein-Levental syndrome
What is Turner syndrome?
 Relatively common disorder caused by the loss of genetic material from one
of the sex chromosomes.
 Affects only females
Genetic causes
 X chromosome monosomy
 X chromosome mosaicism
 X chromosome defects
Symptoms
Clinical features
 Short stature (143-145cm tall)
 Loss of ovarian function
 Hormone imbalances( thyroid, diabetes)
 Stress and emotional deprivation
 Diseases affecting the kidneys, heart, lungs or intestines
 Bone diseases
 Learning problems( esp. in maths)
Gonadal failure
Internal genitalia of patient with gonadal dysgenesis (Turner syndrome),
featuring normal but infantile uterus, normal fallopian tubes, and pale,
glistening "streak" gonads in both broad ligaments.
Diagnosis
 Possible during infancy or early childhood
 A physical exam is the first indication
 The best test is a karyotype, ie a laboratory test presenting the chromosomes
Treatment
 Growth hormone therapy
 Estrogen replacement therapy
 Cardiac surgery (when needed)
 In vitro fertilization (to achieve pregnancy)
 Psychological help
Polycystic Ovarian Syndrome
Sagittal section of a polycystic ovary illustrating
large number of follicular cysts and thickened stroma.
 an inversion of the normal LH/FSH ratio
 lack of ovulation
 increased levels of male hormones ("androgens")
 insulin resistance
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
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
The uterine form of amenorrhea
 Primary
– Uterus congenital anomalies
 Secondary
– Postinflammation intrauterine synechyas
– Endometrium trauma
– Tuberculosis of endometrium
Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis)
 15% of primary amenorrhea
 Normal secondary development & external female genitalia
 Normal female range testosterone level
 Absent uterus and upper vagina & normal ovaries
 Karyotype 46-XX
 15-30% renal, skeletal and middle ear anomalies
COMPLICATIONS OF MENSTRUATION
Premenstrual syndrome
 Symptoms include edema, weight gain, restlessness, irritability, and
increased tension.
 Symptoms must occur in the second half of the menstrual cycle.
 There must be a symptom-free period of at least 7 days in the first half
of the cycle.
 Symptoms must occur in at least 2 consecutive cycles.
 Symptoms must be severe enough to require medical advice or
treatment.
Mastodynia
 Pain, and usually swelling, of the breasts caused by edema and
engorgement of the vascular and ductal systems is termed mastodynia,
or mastalgia.
Treatment
 Management of painful breasts due to fibrocystic changes consists of
support of the breasts, avoidance of methylxanthenes (coffee, tea,
chocolate, cola drinks), and occasional use of a mild diuretic.
 Patients with mastodynia have had improvement with danazol,
bromocriptine, oral contraceptives, and vitamins, though with limited
success. I
 In one study, lisuride maleate, a dopamine agonist, was associated with
a significant decrease in pain.
Dysmenorrhea
 Dysmenorrhea, or painful menstruation, is the most common complaint
of gynecologic patients.
 There are 3 types of dysmenorrhea: (1) primary (no organic cause),
 (2) secondary (pathologic cause),
 (3) membranous (cast of endometrial cavity shed as a single entity).
Dysmenorrhea
 Typically, pain occurs on the first day of the menses, usually about the
time the flow begins, but it may not be present until the second day.
 Nausea and vomiting, diarrhea, and headache may occur.
Treatment of dysmenorrhea
 ANTIPROSTAGLANDINS
 B. ORAL CONTRACEPTIVES
 C. SURGICAL TREATMENT
 D. ADJUVANT TREATMENTS
Abnormal uterine bleeding
 Abnormal uterine bleeding includes:
– abnormal menstrual bleeding
– bleeding due to other causes such as pregnancy, systemic disease,
or cancer.
Patterns of Abnormal Uterine Bleeding
 Menorrhagia (hypermenorrhea)
 Hypomenorrhea (cryptomenorrhea)
 Metrorrhagia (intermenstrual bleeding)
 Polymenorrhea
 Menometrorrhagia
 Oligomenorrhea
 Contact bleeding (postcoital bleeding)
Evaluation of abnormal uterine bleeding
 A. HISTORY
 B. PHYSICAL EXAMINATION
 C. CYTOLOGIC EXAMINATION
 D. ENDOMETRIAL BIOPSY
 H. OTHER DIAGNOSTIC PROCEDURES
Dysfunctional uterine bleeding
Treatment
 A. ADOLESCENTS
 B. YOUNG WOMEN
 C. PREMENOPAUSAL WOMEN
 D. SURGICAL MEASURES
ABNORMAL BLEEDING IN THE CHILDBEARING YEARS
Abnormal bleeding without obvious local cause is not uncommon in women of this age
group. The bleeding may be cyclical or irregular. The uterus may be slightly and symmetrically
enlarged, particularly in parous women.
It is not uncommon for abnormal bleeding of endocrine origin to undergo spontaneous
remission; in young women without abnormal physical signs it is worth waiting for a short time
to see if normal menstruation returns. When abnormal bleeding persists the following options
may be tried:
Under 40 years of age, one can use the combined oral contraceptive pill for non-smoking
and non-obese women. Otherwise non-steroidal anti-inflammatory drugs (NSAID) which inhibit
pros-taglandin synthesis in the endometrium will relieve both menorrhagia and sysmenorrhoea
(e.g. mefe-namic acid 500 mg tds given during ther period). Alternatively, anti-fibrinolysins will
reduce bleeding by inhibiting plasminogen activity that may cause nausea and vomiting in a third
of cases (tranexamic acid is given at a dose of 1.5gtds during the period). In a woman over 40
years of age, heavy bleeding of recent onset should be managed by hyseroscopy and diagnostic
D & C, to exclude endometrial pathology such as endomet-rial hyperplasia.
If nothing sinister is found at D & C, other measures include danazol which competitively
binds sex hormones to their receptors and inhibits their production by direct enzymatic action. It
is given orally as a dose of 200-800 mg daily in divided doses. It sometimes causes unpleasant
masculinizing side effects.
GnRH analogues may be used to inhibit gona-dotrophin secretion but they are expensive
and cause menopausal side effects and osteoporosis. If these measures fail, endometrial resection
or ablation can be considered. About one third of patients will have amenorrhoea, one third will
be improved and one third will be unchanged.
Finally, hysterectomy may be offered when menorrhagia cannot be controlled by any of
these methods and there are still some 7 years before the menopause is expected. The ovaries are
not removed unless involved by pathology or over the age of 50. Between the ages of 45 and 50
the case for their removal is more controversial and needs to be discussed on an individual case
with each patient.
V. Self-assessment tasks:
1. What classifications of abnormalities of menstrual cycle do you know?
2. What is bleeding of juvenile period?
3. Clinical picture of certain forms of abnormalities of menstrual cycle.
4. Methods of non-hormonal hemostasis by bleedings.
5. When can hormonal hemostasis be prescribed?
6. What are the indications for surgical treatment of bleedings?
7. Make up a plan of examination of a patient with abnormalities of
menstrual function.
8. Prescribe treatment to the patient with
function.
abnormalities of menstrual
VI. Literature.
VI. Literature.
1. American Academy of Pediatrics Committee on Quality Improvement,
Subcommittee on Urinary Tract Infection. Practice Parameter: The diagnosis,
treatment and evaluation of the initial urinary tract infection in febrile infants and
young children. Pediatrics 1999;103;4:843–852.
2. Sanfilippo JS. Pediatric and Adolescent Gynecology, 2nd Ed. Philadelphia: WB
Saunders, 2001:227–231.
3. Reiter EO, Lee PA. Adolescent endocrinology: delayed puberty. Adolesc Med
2002;13 (1):101–118.
4. Larsen PR. Williams Textbook of Endocrinology, 10th Ed. Elsevier,
2003:1171–1202.
5. Stenchever MA. Comprehensive Gynecology, 4th Ed. Mosby, 2001:280–288.
6. Kaplowitz PB. Reexamination of the age limit for defining when puberty is
precocious in girls in the United States: implication for evaluation and treatment.
Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric
Endocrine Society. Pediatrics 1999;104 (4 Pt 1):936–941.
7. Antoniazzi F, Zamboni G. Central precocious puberty: current treatment
options. Paediatr Drugs 2004;6 (4):211–231.
8. Speroff L, Glass RH, Kase NG. Clinical Gynecologic Endocrinology and
Infertility, 5th Ed. Baltimore: Williams & Wilkins, 1994:380–382.
9. Eugster EA, Rubin SD, Reiter EO, et al. Tamoxifen treatment for precocious
puberty in McCune-Albright syndrome: a multicenter trial. J Pediatr 2003;143
(1):60–66.
10. Speroff L, Glass RH, Kase NG. Clinical Gynecologic Endocrinology and
Infertility, 5th Ed. Baltimore: Williams & Wilkins, 1994:340–342.
11. Sanfilippo JS. Pediatric and Adolescent Gynecology, 2nd Ed. Philadelphia:
WB Saunders, 2001:277–287.
12. Sanfilippo JS. Pediatric and Adolescent Gynecology, 2nd Ed. Philadelphia:
WB Saunders, 2001:605–608.