ERM2 Menstrual Path

• -Day 1 = first day of bleeding
• -Avg cycle length = 28 days
• -Follicular Phase: variable
• -Luteal Phase: always 14 days

• cycle length > 6 mo
• -primary: never experienced bleeding
• -secondary: previous bleeding experienced

-interval 35-180 days

interval shorter than 21 days

• 1. Central
•      -hypothalamus (GnRH)
•      -pituitary (LH, FSH)

2. Ovarian

3. Outflow Tract Causes (uterus)

• 1. Stress (weight loss, exercise)
• 2. Psychogenic disorders
• 3. GnRH dysfunction
• 4. GnRH receptor gene mutation

• -at least 22% lean-fat ratio required for normal menses
• -depends on type of exercise (runners but not swimmers)
• -critical threshold under which do not menstruate

• 1. Anorexia Nervosa
• 2. Pseudocyesis

• -wt loss leading to less than 85% expected
• -not just weight loss that causes amenorrhea
• -can have hyperkalemia --> death

• 1. Kallman Syndrome
• 2. Lawrence-Moon-Biedl-Bardet Syndrome
• 3. Idiopathic hypergonadotropic hypogonadism

• -primary amenorrhea
• -hyposmia/anosmia
• -lack of secondary sexual development
• -color blindness

• -GnRH neurons originate in olfactory epithelium and migrate to the hypothalamic region of the brain
• -in Kallman's the neurons don't migrate and don't get activated

-two forms: KAL1 and KAL2

• -x-linked
• -mutation in anosmin
• -no cleft lip

• -autosomal dominant
• -mutation in FGFR1
• -associated with cleft lip

• -amenorrhea
• -retinitis pigmentosa
• -obesity
• -mental retardation
• -lack of secondary sexual development

• 1. Tumors (functional or non-functional, NF more common)
• 2. Pituitary necrosis (Sheehan's Syndrome: hypotension --> pituitary infarct)
• 3. Rare: empty sella syndrome, infiltrative diseases, head trauma and irradiation

• 1. Hormone producing tumors
•      -PRL (30%)
•      -GH (18%)
• 2. Gonadotropin Deficiency (hormone or receptor)

• 1. Gonadal Dysgenesis
•      -Turner's Syndrome
•      -pure gonadal dysgenesis
• 2. Premature loss of oocytes
• 3. Ovarian insensitivity

-usually 45XO (46XX)

• Clinical Features
•      -short stature
•      -broad chest
•      -low set ears
•      -web neck
•      -congenital heart disease
•      -hypothyroidism

• -46XX
• -fleshy streak instead of ovaries
• -can be 46XY

• 1. Muellarian Anomalies (congenital)
• 2. Androgen Insensitivity Syndrome (46XY)
• 3. Vaginal Agenesis
• 4. Imperforate hymen
• 5. Intrauterin adhesions (instrumentation)

-5-10% of reproductive aged women

• 1. Reproductive Disruption
•      -androgen excess --> hirsutism
•      -chronic anovulation (oligomenorrhea)
•      -polycystic ovaries
• 2. Metabolic Abnormalities
•      -insulin resistance (diabetes)
•      -obesity

-follicles are arrested in midantral stage --> cysts

-theca cell layer hyperplasia (excessive androgens: maybe due to abnormal enzyme activity)

-increased GnRH activity --> increased LH --> more androgen

• -increased free FAs --> hyperinsulinemia
• -increased theca cell production of androgen
• -decreased SHBG (increase free T)
• -lower IGFBP (increase theca cell production of androgen)
• -inflammatory cytokines

• 1. OCPs: anovulation, hair
• 2. Anti-androgens (Spironolactone): blocks T signaling, hair
• 3. Progesterone: anovulation
• 4. IVF/Ovulation induction (aromatase inhibitor): infertility

• 1. Retrograde Menstruation
• 2. Hematologic Spread
• 3. Lymphatic Spread
• 4. Coelomic Metaplasia
• 5. Genetic Factors
• 6. Immune Factors

-laparscopy

• -estrogen suppression (control pain)
• -NSAIDs
• -OCPs (continuous)
• -Progestins
• -Danazol
• -GnRH-agnoist (with add back therapy)

• -in women with endometriosis the endometrium expresses COX2 and aromatase inhibitors
• -PGs have a positive effect on aromatase
• -estrogens active COX2

-positive feedback

• -breakthrough bleeding
• -weight gain
• -breast tenderness
• -bloating
• -nausea

• -testosterone derivative
• -anovulation, hyperandrogenic, hypoestrogenic

-use in mild endometriosis

-adverse effects: acne, edema, wt gian, hirsutism, flushes, spotting, atrophic vaginitis

rarely used

• -initially stimulate FSH/LH release (flare)
• -downregulate GnRH receptors ("pseudomenopause")
• -expensive
• -risk of osteoporosis

• -estrogens +/- porgestins
• -progestins
• -progestins + bisphosphonate
• -tibolone (synthetic steroid with E and P activity)

• -vaporization with laser
• -excision

• -presence of endometrial tissue within the myometrium
• -enlarged, tender, uterus
• -dysmenorrhea

• Management:
• -analgesics
• -OCPs
• -GnRHa
• -hysterectomy

• <0.5% become malignant
• -benign smooth muscle tumors of the uterus
• -mroe common in African American

• -Intramural
• -Subserosal (outer)
• -Submucosal (cavity)

• -asymptomatic
• -menorrhagia
• -infertility
• -pregnancy complications
• -pain
• -degeneration (lose blood supply)
• -parasitic fibroids

• -watch and wait
• -anagelsics/OCPs
• -medical shrinkage with GnRHa (temporary)
• -radiological (uterine artery embolization)
• -myomectomy
• -hysterectomy