Neuro-Endocrinal regulation of Menstrual cycle

Neuro-Endocrinal regulation of Menstrual cycle

1. NEUROENDOCRINAL NEUROENDOCRINAL
REGULATION OF REGULATION OF
MENSTRUAL CYCLEMENSTRUAL CYCLE

2. 
NEUROENDOCRINAL NEUROENDOCRINAL
REGULATION OF REGULATION OF
MENSTRUAL CYCLEMENSTRUAL CYCLE – – is a is a
complex, genetically determinate complex, genetically determinate
system of inter-control of genitals, system of inter-control of genitals,
central nervous system and target central nervous system and target
organs. Formation of reproductive organs. Formation of reproductive
system starts in antenatally and system starts in antenatally and
finishes at the age of 18-21.finishes at the age of 18-21.

3. THERE ARE 5 LEVELS THERE ARE 5 LEVELS
OF MENSTRUAL CYCLE OF MENSTRUAL CYCLE
REGULATION.REGULATION.
1 Target organs.1 Target organs.

They include external and internal genital They include external and internal genital
organs, mammary glands, bone tissue and organs, mammary glands, bone tissue and
skin.skin.

Target organs have receptors for steroid Target organs have receptors for steroid
hormones.hormones.

Due to the influence of sex hormones on Due to the influence of sex hormones on
these organs there originates the formation of these organs there originates the formation of
secondary sexual character, cyclical processes secondary sexual character, cyclical processes
in endometrium, vagina.in endometrium, vagina.

4. 2. Ovaries.2. Ovaries.

Steroid hormones in the ovary are being Steroid hormones in the ovary are being
synthesized due to the action pituitary synthesized due to the action pituitary
hormones.hormones.

The hormones synthesis process inside the The hormones synthesis process inside the
ovary was entitled steroidogenesis.ovary was entitled steroidogenesis.

Adrenal glands and adipose tissue synthesize Adrenal glands and adipose tissue synthesize
steroid hormones also.steroid hormones also.

Steroid hormones are being synthesized from Steroid hormones are being synthesized from
cholesterol and have the same nature.cholesterol and have the same nature.

Schematically this process can be represented Schematically this process can be represented
in the following way: cholesterol – pregnenolone in the following way: cholesterol – pregnenolone
– androgens – estrogens.– androgens – estrogens.

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6. 
Ovaries synthesize 3 types of hormones:Ovaries synthesize 3 types of hormones:
estrogens, gestogens, androgens. Female estrogens, gestogens, androgens. Female
organism producer 3 fractions of estrogens.organism producer 3 fractions of estrogens.

EstradiolEstradiol - - is the most active one and is being is the most active one and is being
produced by ovaries.produced by ovaries.

EstroneEstrone – – less active, basically produced by less active, basically produced by
adipose tissue. adipose tissue.

EstriolEstriol – – is a result of transformation of is a result of transformation of
estradiol, estrone and androgens of estradiol, estrone and androgens of
epinephroses. Estriol is major hormone of epinephroses. Estriol is major hormone of
pregnancy with minimal hormonal activity.pregnancy with minimal hormonal activity.

7. 
Progesterone –Progesterone – is hormone of yellow is hormone of yellow
body of ovary and is a gestogen.body of ovary and is a gestogen.

Major androgen of ovary is a Major androgen of ovary is a
testosteronetestosterone, which is produced by cells , which is produced by cells
of internal theca. Testosterone is not very of internal theca. Testosterone is not very
active.active.

Under the influence of enzyme 5-α-Under the influence of enzyme 5-α-
reductase, it is transformed into more reductase, it is transformed into more
active hormone – dehydrotestosterone.active hormone – dehydrotestosterone.

8. 
Most estrogens and androgens merge Most estrogens and androgens merge
with sex steroid-binding globulin (SSBG).with sex steroid-binding globulin (SSBG).

Less amount of estrogens merge with Less amount of estrogens merge with
albumin and erythrocytes.albumin and erythrocytes.

Only one percent of estrogens remains Only one percent of estrogens remains
free and influences the target organs. free and influences the target organs.

SSBG is synthesized by liver, its quantity SSBG is synthesized by liver, its quantity
is proportional to estrogen level, and is proportional to estrogen level, and
decreases under the influence of decreases under the influence of
androgens.androgens.

Today there are discovered 2 Today there are discovered 2
progesterone-binding proteins.progesterone-binding proteins.

9. PHYSIOLOGIC EFFECTS PHYSIOLOGIC EFFECTS
OF ESTROGENOF ESTROGEN
ON FEMALE ORGANISM ON FEMALE ORGANISM

Uterus. Uterus. Estrogens determine the proliferation Estrogens determine the proliferation
processes in endometrium, growth of processes in endometrium, growth of
myometrium and uterine tubes.myometrium and uterine tubes.

Mammary glands. Mammary glands. Stimulate growth.Stimulate growth.

Bone tissue. Bone tissue. Estrogens are parathormone Estrogens are parathormone
antagonists. They hinder development of antagonists. They hinder development of
osteoporosis and condense growth zones in osteoporosis and condense growth zones in
bones.bones.

Cardiovascular system - iCardiovascular system - increases the ncreases the
arterial pressure and vascular tone.arterial pressure and vascular tone.

10. 
Circulatory system. Circulatory system. Increases amount of Increases amount of
fibrin.fibrin.

Mineral metabolism. Mineral metabolism. Estrogens influence the Estrogens influence the
natrium metabolism they attract sodium from natrium metabolism they attract sodium from
tissues and can cause the edemas.tissues and can cause the edemas.

Lipidic metabolism. Lipidic metabolism. Increases quantity of Increases quantity of
high-density β-lipoproteins this is anti-high-density β-lipoproteins this is anti-
atherosclerotic effect.atherosclerotic effect.

Central nervous system. Central nervous system. Estrogens shape Estrogens shape
optimal neuropsychic. They change synthesis of optimal neuropsychic. They change synthesis of
pituitary and hypothalamus hormone.pituitary and hypothalamus hormone.

11. PHYSIOLOGIC EFFECTS PHYSIOLOGIC EFFECTS
OF PROGESTERONE.OF PROGESTERONE.

Uterus. Uterus. In case of sufficient concentration of In case of sufficient concentration of
estrogens, progesterone exerts influence upon estrogens, progesterone exerts influence upon
tissues. tissues.

Progesterone creates the evident anti-Progesterone creates the evident anti-
proliferative effect and conditions the secretion proliferative effect and conditions the secretion
processes in endometrium.processes in endometrium.

Besides, progesterone furthers myometrium Besides, progesterone furthers myometrium
growth.growth.

Mammary gland. Mammary gland. Along with estrogens and Along with estrogens and
prolactin, progesterone conditions the tissue prolactin, progesterone conditions the tissue
development of. Besides, progesterone furthers development of. Besides, progesterone furthers
lactation.lactation.

12. 
Cardiovascular system. Cardiovascular system. Progesterone Progesterone
decreases vessels tone and arterial decreases vessels tone and arterial
pressure.pressure.

Circulatory system. Circulatory system. Progesterone does Progesterone does
not influence the amount of fibrin.not influence the amount of fibrin.

Mineral metabolism. Mineral metabolism. Progesterone has Progesterone has
diuretic effect.diuretic effect.

Central nervous system. Central nervous system.
Progesterone may cause depressions. It Progesterone may cause depressions. It
shows evident anti-gonadotrophic action.shows evident anti-gonadotrophic action.

13. EFFECTS OF EFFECTS OF
ANDROGENS.ANDROGENS.

- Androgens is normal concentration are - Androgens is normal concentration are
synergists of estrogens.synergists of estrogens.

- In high concentrations androgens show evident - In high concentrations androgens show evident
anti-gonadotrophic action and further the anti-gonadotrophic action and further the
development of secondary male sexual development of secondary male sexual
characters.characters.

- During antenatal and postnatal periods - During antenatal and postnatal periods
increase of level causes change of central increase of level causes change of central
nervous system.nervous system.

14. 

3. Hypophysis.3. Hypophysis.

Hypophysis is divided into 2 lobes: Hypophysis is divided into 2 lobes:
anterior – adenohypophysis and posterior anterior – adenohypophysis and posterior
– neurohypophysis.– neurohypophysis.

Adenohypophysis consists of groups of Adenohypophysis consists of groups of
cells, these groups of cells are responsible cells, these groups of cells are responsible
for the synthesis of the following for the synthesis of the following
hormones:hormones:

growth hormone (somatotropic hormone – growth hormone (somatotropic hormone –
STH);STH);

15. 
thyrotropin (thyroid stimulating hormone – thyrotropin (thyroid stimulating hormone –
TSH);TSH);

prolactin (PRL);prolactin (PRL);

follicle-stimulating hormone (FSH);follicle-stimulating hormone (FSH);

luteinizing hormone (LH);luteinizing hormone (LH);

adrenocorticotropic hormone (ACTH);adrenocorticotropic hormone (ACTH);

melanotropic hormone (MH).melanotropic hormone (MH).

16. 
LH, FSH, PRL are major hormones which LH, FSH, PRL are major hormones which
regulate menstrual cycle.regulate menstrual cycle.

But it is only possible under condition of But it is only possible under condition of
optimal concentrations of other pituitary optimal concentrations of other pituitary
hormones.hormones.

Synthesis of pituitary hormones is realized Synthesis of pituitary hormones is realized
due to stimulating impact of due to stimulating impact of
hypothalamus.hypothalamus.

PRL synthesis depends on dopamine PRL synthesis depends on dopamine
concentration.concentration.

PRL concentration increases when PRL concentration increases when
dopamine level decreases.dopamine level decreases.

17. 
Hormones are not synthesized at Hormones are not synthesized at
the posterior lobe of hypophysis.the posterior lobe of hypophysis.

Oxytocin and vasopressin are Oxytocin and vasopressin are
synthesized in hypothalamus, but synthesized in hypothalamus, but
accumulated in posterior lobe of accumulated in posterior lobe of
hypophysis.hypophysis.

18. 
4. Hypothalamus.4. Hypothalamus.

Nucleuses of hypothalamus synthesizes Nucleuses of hypothalamus synthesizes
the following neurohormones: libertines the following neurohormones: libertines
and statines.and statines.

The libertines stimulate The libertines stimulate
adenohypophysis, statines inhibit it.adenohypophysis, statines inhibit it.

These hormones were entitled releasing These hormones were entitled releasing
hormones.hormones.

19. 
Liberines include the following hormones:Liberines include the following hormones:

adrenocorticotropin-releasing hormone adrenocorticotropin-releasing hormone
(ACTH-RG);(ACTH-RG);

thyrotropin-releasing hormone (TRG);thyrotropin-releasing hormone (TRG);

gonadotropin-releasing hormone (GN-gonadotropin-releasing hormone (GN-
RG);RG);

growth hormone-releasing hormone growth hormone-releasing hormone
(somatoliberin GH-RG);(somatoliberin GH-RG);

melanoliberin (M-RG)/melanoliberin (M-RG)/

20. 
Statines Statines include the following include the following
hormones:hormones:

somatostatin;somatostatin;

dopamine (major prolactin-dopamine (major prolactin-
inhibiting factor).inhibiting factor).

21. 
Synthesis of neurohormones descends Synthesis of neurohormones descends
not only in hypothalamus.not only in hypothalamus.

Somatostatin is synthesized in tissues of Somatostatin is synthesized in tissues of
thyroid gland, bowels.thyroid gland, bowels.

Other hypothalamus peptides – gastrin, Other hypothalamus peptides – gastrin,
cholecystokinin, enkephaline are cholecystokinin, enkephaline are
synthesized by other tissues also.synthesized by other tissues also.

They create a regulation system entitled They create a regulation system entitled
“diffused neuroendocrinal system of “diffused neuroendocrinal system of
organism”.organism”.

22. 
5. Extra-hypothalamic structures.5. Extra-hypothalamic structures.

Epiphysis, limbic system, celebrum Epiphysis, limbic system, celebrum
tonsil, hippocampus influence the tonsil, hippocampus influence the
reproductive function.reproductive function.

They are related to extra-hypothalamic They are related to extra-hypothalamic
structures.structures.

Function of hypothalamus can be Function of hypothalamus can be
stimulated or inhibited by enkephalins, stimulated or inhibited by enkephalins,
endorphins, neuropeptides.endorphins, neuropeptides.

23. NEUROENDOCRINAL NEUROENDOCRINAL
REGULATION REGULATION
OF MENSTRUAL CYCLE.OF MENSTRUAL CYCLE.

At the age of 10-12 years reproductive system At the age of 10-12 years reproductive system
starts its development.There are several starts its development.There are several
theories, which explain activation of theories, which explain activation of
hypothalamo-pituitary-ovarian system.hypothalamo-pituitary-ovarian system.

1.Theory of after-ripening. According to this 1.Theory of after-ripening. According to this
theory sensitivity of hypothalamus to the steroid theory sensitivity of hypothalamus to the steroid
hormones changes with the age. Besides, hormones changes with the age. Besides,
sensitivity of ovaries to gonadotropin increases sensitivity of ovaries to gonadotropin increases
also.also.

24. 
2.Theory of resonance. According to 2.Theory of resonance. According to
this theory increase in electrical this theory increase in electrical
activity of hypothalamus nucleuses activity of hypothalamus nucleuses
stimulates an increase of GN-RG stimulates an increase of GN-RG
level.level.

3.Theory of block release. 3.Theory of block release.
According to this theory at the start According to this theory at the start
of pubescence epiphysis function of pubescence epiphysis function
decreases and hypothalamus decreases and hypothalamus
function increases.function increases.

25. 
Activation of hypothalamus makes it Activation of hypothalamus makes it
drastically sensible to decrease in drastically sensible to decrease in
estrogen’s concentration.estrogen’s concentration.

Next, it synthesized GN-RG, which Next, it synthesized GN-RG, which
stimulates production of FSH and LH.stimulates production of FSH and LH.

Gonadotropins influence the process of Gonadotropins influence the process of
growth and development of follicle growth and development of follicle
(“folliculogenesis”) in ovaries.(“folliculogenesis”) in ovaries.

This descending process is entitled This descending process is entitled
direct relationship.direct relationship.

26. 
Ovary of newborn girl contains 400-500 Ovary of newborn girl contains 400-500
thousands of primary ovarian follicle.thousands of primary ovarian follicle.

Only 400 follicles ripen and reach the Only 400 follicles ripen and reach the
ovulation.ovulation.

In the ovary there starts the development In the ovary there starts the development
of several primary ovarian follicles under of several primary ovarian follicles under
the influence of FSH. the influence of FSH.

In the beginning they grow independently.In the beginning they grow independently.

27. 
Later on, their growth depends on the FSH level Later on, their growth depends on the FSH level
and the sensitivity of follicle to the FSH.and the sensitivity of follicle to the FSH.

Therefore, only one follicle amounts to the size Therefore, only one follicle amounts to the size
of pre-ovulatory, other undergo atrophy.of pre-ovulatory, other undergo atrophy.

Wall of antrum-containing follicle has 3 sheaths: Wall of antrum-containing follicle has 3 sheaths:
interstitial, internal theca and granulosis.interstitial, internal theca and granulosis.

These sheaths have differing sensibility to These sheaths have differing sensibility to
gonadotropic hormones.gonadotropic hormones.

Intersticium and theca are more sensible to LH, Intersticium and theca are more sensible to LH,
and granulosis – to FSH.and granulosis – to FSH.

28. 
Follicle synthesizes steroid hormones. Follicle synthesizes steroid hormones.

This process is called steroidogenesis.This process is called steroidogenesis.

This process is integrated: theca and This process is integrated: theca and
intersticium synthesize steroids up to intersticium synthesize steroids up to
androgen fraction, and granulosis androgen fraction, and granulosis
produces estrogens.produces estrogens.

Increase in estrogen’s concentration Increase in estrogen’s concentration
depresses function of hypophysis.depresses function of hypophysis.

This process is called negative This process is called negative
inverse relationship.inverse relationship.

30. 
It takes place in the early pubertal period when It takes place in the early pubertal period when
menstrual cycles are monophase.menstrual cycles are monophase.

Positive inverse relationship is Positive inverse relationship is

characterized by maximum estrogen’s characterized by maximum estrogen’s
concentration.concentration.

Consequently there occurs keen increase of Consequently there occurs keen increase of
honadotropines and libertines.honadotropines and libertines.

Ovulation follows this process.Ovulation follows this process.

Ovulation process is a histochemical process.Ovulation process is a histochemical process.

Estrogens, prostaglandins and histamine Estrogens, prostaglandins and histamine
influence the sheath of follicle and cause its influence the sheath of follicle and cause its
rupture.rupture.

31. 
Granulosis cells are transformed into the Granulosis cells are transformed into the
yellow body under the influence of LH yellow body under the influence of LH
after ovulation.after ovulation.

The yellow body synthesizes The yellow body synthesizes
progesterone.progesterone.

Increase of progesterone inhibits the Increase of progesterone inhibits the
synthesis of LH.synthesis of LH.

This causes the death of the yellow body. This causes the death of the yellow body.

32. 
Ovarian cycle is Ovarian cycle is a consistent process of a consistent process of
growth and development of follicle, ovulation, growth and development of follicle, ovulation,
development and death of the yellow body.development and death of the yellow body.

Ovarian cycle is divided into 3 phases:Ovarian cycle is divided into 3 phases:

Follicular phaseFollicular phase is characterized by growth is characterized by growth
and development of follicle.and development of follicle.

It lasts 12-14 days.It lasts 12-14 days.

Ovulatory phaseOvulatory phase – it several hours. – it several hours.

Lutein phaseLutein phase is characterized by development is characterized by development
and functioning of the yellow body.and functioning of the yellow body.

33. 
Uterine cycle is Uterine cycle is a cyclic process in the ovary, a cyclic process in the ovary,
which causes cyclic changes in the which causes cyclic changes in the
endometrium. It has 4 phases:endometrium. It has 4 phases:

Desquamation. Desquamation. Decrease of steroid hormones Decrease of steroid hormones
causes spasm, ischemia and rejection spiroid causes spasm, ischemia and rejection spiroid
artery of decidual sphere of endometrium.artery of decidual sphere of endometrium.

First day of desquamation corresponds to the First day of desquamation corresponds to the
first day of menstruation and menstrual cycle.first day of menstruation and menstrual cycle.

Regeneration. Regeneration. It corresponds to the early It corresponds to the early
period of follicular phase in the ovary.period of follicular phase in the ovary.

Regeneration lasts 4-5 days.Regeneration lasts 4-5 days.

It starts with epithelization of endometrium.It starts with epithelization of endometrium.

34. 
Proliferation. Proliferation. It lasts 5-7 days and results in It lasts 5-7 days and results in
ovulation.ovulation.

It corresponds to the late period of follicular It corresponds to the late period of follicular
phase in the ovary.phase in the ovary.

Is characterized by proliferation of epithelium Is characterized by proliferation of epithelium
and development of spiroid arteries.and development of spiroid arteries.

Secretion. Secretion. It corresponds to lutein phase in the It corresponds to lutein phase in the
ovary. It lasts 10-12 days. ovary. It lasts 10-12 days.

The process of proliferation is superseded by The process of proliferation is superseded by
secretion.secretion.

If pregnancy did not take place, cyclic processes If pregnancy did not take place, cyclic processes
in the system uterus-ovaries-hypothalamic-in the system uterus-ovaries-hypothalamic-
pituitary system repeat.pituitary system repeat.

36. MENSTRUAL DISORDERSMENSTRUAL DISORDERS
ETIOLOGYETIOLOGY

Nervous diseases.Nervous diseases.

Mental diseases.Mental diseases.

Malnutrition.Malnutrition.

Some occupational hazards.Some occupational hazards.

Systemic and gynecologic inflammatory diseases.Systemic and gynecologic inflammatory diseases.

Illness of the haemopoiesis, cardiovascular and other Illness of the haemopoiesis, cardiovascular and other
systems.systems.

Gynecologic operations.Gynecologic operations.

Puberty disorders.Puberty disorders.

Age-specific reconstruction of the functional state in Age-specific reconstruction of the functional state in
hypothalamic-pituitary-ovarian axis in the menopause.hypothalamic-pituitary-ovarian axis in the menopause.

37. AMENORRHOEAAMENORRHOEA

Pathological primary amenorrhoea – when the Pathological primary amenorrhoea – when the
patient has never menstruated.patient has never menstruated.

Pathological secondary amenorrhoea – when Pathological secondary amenorrhoea – when
the periods are absent for more than 6 months.the periods are absent for more than 6 months.

Physiological amenorrhoea – before puberty, Physiological amenorrhoea – before puberty,
during pregnancy and lactation, and after the during pregnancy and lactation, and after the
menopause.menopause.

False amenorrhoea – when the flow does not False amenorrhoea – when the flow does not
escape because of some obstruction.escape because of some obstruction.

True amenorrhoea – when the endometrial True amenorrhoea – when the endometrial
cycle is absent.cycle is absent.

38. TRUE PATHOLOGICAL TRUE PATHOLOGICAL
AMENORRHOEAAMENORRHOEA
1.Uterine disorders.1.Uterine disorders.

the uterus may be congenitally defective;the uterus may be congenitally defective;

the endometrium atrophies after the endometrium atrophies after
irradiation with X-ray or radium, and irradiation with X-ray or radium, and
hysterectomy.hysterectomy.

39. 2. Ovarian disorders.2. Ovarian disorders.

failure of ovarian development occurs in cases of failure of ovarian development occurs in cases of
gonadal dysgenesis;gonadal dysgenesis;

Stein-LeventhalStein-Leventhal syndrome is a disorder of unknown syndrome is a disorder of unknown
cause.cause.

After some years of normal menstruation After some years of normal menstruation
amenorrhoea occurs with hirsuties.amenorrhoea occurs with hirsuties.

Both ovaries are enlarged and contain multiple Both ovaries are enlarged and contain multiple
small follicular cysts.small follicular cysts.

There is a block in the normal conversion of There is a block in the normal conversion of
progesterone to estrogen so that an intermediate progesterone to estrogen so that an intermediate
androgen substance androstendione appears in androgen substance androstendione appears in
excess.excess.

The urinary excretion of estrogens is normal or low, The urinary excretion of estrogens is normal or low,
while that of pregnantriol (a metabolic product of while that of pregnantriol (a metabolic product of
certain androgens) is raised;certain androgens) is raised;

arrhenoblastoma is a very rare cause of amenorrhoea;arrhenoblastoma is a very rare cause of amenorrhoea;

ovarian infections or new growths as processes ovarian infections or new growths as processes
destroying all ovarian tissue.destroying all ovarian tissue.

40. 3. Pituitary disorders.3. Pituitary disorders.

There is of production of gonadotrophic There is of production of gonadotrophic
hormones.hormones.

Amenorrhoea is one aspect of general Amenorrhoea is one aspect of general
disorders and the gynecologist is seldom disorders and the gynecologist is seldom
responsible for treatment.responsible for treatment.

Pituitary infantilism (Levi-Loraine syndrome). Pituitary infantilism (Levi-Loraine syndrome).
The adult resembles a child. No effective The adult resembles a child. No effective
treatment is known.treatment is known.

Pituitary cachexia (Simmond’s disease). This Pituitary cachexia (Simmond’s disease). This
is usually due to ischemic necrosis of the is usually due to ischemic necrosis of the
pituitary glands (hypophysis) due to pituitary glands (hypophysis) due to
thrombosis of pituitary vessels after thrombosis of pituitary vessels after
postpartum hemorrhage and collapse.postpartum hemorrhage and collapse.

Failure of lactation is followed by genital Failure of lactation is followed by genital
atrophy, loss of pubic hair, weakness, atrophy, loss of pubic hair, weakness,
anorexia.anorexia.

41. 
Treatment with cortisone, thyroxin and anabolic Treatment with cortisone, thyroxin and anabolic
steroids may cause some improvement.steroids may cause some improvement.

Adipogenital dystrophy is characterized by Adipogenital dystrophy is characterized by
dwarfing, adiposity and genital infantilism, and is dwarfing, adiposity and genital infantilism, and is
usually caused by a craniopharyngioma that usually caused by a craniopharyngioma that
involves the pituitary gland and hypothalamus. involves the pituitary gland and hypothalamus.
The treatment is surgical.The treatment is surgical.

In acromegaly the eosinophilic adenoma of the In acromegaly the eosinophilic adenoma of the
pituitary gland may destroy the gonadotrophic pituitary gland may destroy the gonadotrophic
cells, and the same may happen with other cells, and the same may happen with other
pituitary tumors.pituitary tumors.

Small pituitary adenoma may secrete prolactin Small pituitary adenoma may secrete prolactin
and cause amenorrhoea with galactorrhoea.and cause amenorrhoea with galactorrhoea.

42. 4.Other endocrine disorders.4.Other endocrine disorders.

Amenorrhoea occurs:Amenorrhoea occurs:

in severe cases of hyperthyreoidism, in severe cases of hyperthyreoidism,
myxoedema and cretinism;myxoedema and cretinism;

in some cases of diabetes;in some cases of diabetes;

in Addison’s disease;in Addison’s disease;

with adrenocortical tumors or with adrenocortical tumors or
hyperplasia.hyperplasia.

43. 
5. Nervous disorders5. Nervous disorders (stress (stress
or hypothalamic amenorrhoea). or hypothalamic amenorrhoea).
This is the commonest type of This is the commonest type of
secondary amenorrhoea, and secondary amenorrhoea, and
may be the result of emotional may be the result of emotional
disturbances.disturbances.

44. 
6.Disorders of general health and 6.Disorders of general health and
nutrition.nutrition. Any chronic or severe illness Any chronic or severe illness
(including nutritional deficiency) will (including nutritional deficiency) will
cause amenorrhoea.cause amenorrhoea.

7.Oral contraception.7.Oral contraception. A delayed first A delayed first
period is common after stopping oral period is common after stopping oral
contraception. More prolonged contraception. More prolonged
amenorrhoea sometimes occurs.amenorrhoea sometimes occurs.

45. DIAGNOSISDIAGNOSIS

General examination;General examination;

Special gynecologic examination;Special gynecologic examination;

Ultrasonic;Ultrasonic;

X-ray;X-ray;

Hormonal tests.Hormonal tests.

46. TREATMENTTREATMENT

Sedative therapy;Sedative therapy;

Vitamin therapy;Vitamin therapy;

Adequate nutrition, a special diet intended to Adequate nutrition, a special diet intended to
decrease the body weight;decrease the body weight;

Physiotherapy (endonasal electrophoresis with Physiotherapy (endonasal electrophoresis with
2% solution of vitamin B1, 0.25% solution of 2% solution of vitamin B1, 0.25% solution of
dyphenhydramine hydrochloride).dyphenhydramine hydrochloride).

Drugs suppressing prolactin secretion Drugs suppressing prolactin secretion
(bromocriptine, parlodel, dostineks).(bromocriptine, parlodel, dostineks).

Hormonal therapy of the cyclic hormones Hormonal therapy of the cyclic hormones
(estrogens followed by progesterone).(estrogens followed by progesterone).

47. DISFUNCTIONAL UTERINE DISFUNCTIONAL UTERINE
BLEEDINGBLEEDING

Disfunctional, or anovulatory Disfunctional, or anovulatory
uterine bleeding is associated uterine bleeding is associated
with anovulation caused by with anovulation caused by
impaired or unestablished impaired or unestablished
functional relationships in the functional relationships in the
hypothalamic-pituitary-ovarian hypothalamic-pituitary-ovarian
axis.axis.

48. ClassificationClassification

In juvenile age;In juvenile age;

In reproductive age;In reproductive age;

In the premenopausal period.In the premenopausal period.

49. 
Dysfunctional uterine Dysfunctional uterine
bleedings may be divided bleedings may be divided
into anovulatory and into anovulatory and
ovulatory ones.ovulatory ones.

50. 
Anovulatory bleedings are induced by the Anovulatory bleedings are induced by the
absence of ovulation and luteal phase of absence of ovulation and luteal phase of
the cycle.the cycle.

Anovulatory uterine bleeding develops in Anovulatory uterine bleeding develops in
patients with:patients with:

persistence of an ovarian follicle; persistence of an ovarian follicle;
persistent follicles release a large number persistent follicles release a large number
of estrogens;of estrogens;

atresia of a few follicles; atresia of some atresia of a few follicles; atresia of some
small follicles is associated with small follicles is associated with
hypoestrogenism.hypoestrogenism.

51. 
Both account for continuous, monotonous Both account for continuous, monotonous
secretion of estrogens.secretion of estrogens.

Ovulation does not occur and the corpus luteum Ovulation does not occur and the corpus luteum
fails to form.fails to form.

Excessive proliferation of the endometrium Excessive proliferation of the endometrium
occurs as a result of prolonged occurs as a result of prolonged
exposure to estrogens in both processes. exposure to estrogens in both processes.

Persistent and atretic follicles undergo Persistent and atretic follicles undergo
involution.involution.

The level of hormones (estrogens) is decreased The level of hormones (estrogens) is decreased
in the blood, and bleeding develops. in the blood, and bleeding develops.

53. 
Circulation in the endometrium is Circulation in the endometrium is
impaired, the capillary permeability is impaired, the capillary permeability is
decreased, and the sites of dystrophy and decreased, and the sites of dystrophy and
necrosis are manifested.necrosis are manifested.

The necrotic mucosa is rejected slowly, The necrotic mucosa is rejected slowly,
which causes prolonged bleeding. which causes prolonged bleeding.

Dysfunctional uterine bleedings are not Dysfunctional uterine bleedings are not
attended with pain.attended with pain.

54. CLINICAL PICTURECLINICAL PICTURE

Amenorrhoea: in 4-8 weeks in persistent follicle; Amenorrhoea: in 4-8 weeks in persistent follicle;
3-4 months in atretic follicles;3-4 months in atretic follicles;

Bleedings are more abundant in persistent Bleedings are more abundant in persistent
follicles, being occasionally profuse;follicles, being occasionally profuse;

Anemia;Anemia;

Decrease the patient’s working capacity;Decrease the patient’s working capacity;

General fatigue;General fatigue;

Headache;Headache;

Poor appetite;Poor appetite;

Sleep;Sleep;

Pale skin;Pale skin;

Tachycardia;Tachycardia;

Decreased blood pressure.Decreased blood pressure.

55. DIAGNOSISDIAGNOSIS

Diagnosis is based on general and Diagnosis is based on general and
gynecologic examination. At general gynecologic examination. At general
examination one should pay attention to examination one should pay attention to
the typical sings:the typical sings:

bleedings that follow the suppression of bleedings that follow the suppression of
menses;menses;

monophase basal body temperature;monophase basal body temperature;

high or low karyopycnotic index.high or low karyopycnotic index.

56. 
Dysfunctional uterine bleedings should be Dysfunctional uterine bleedings should be
differentiated from many disease forms differentiated from many disease forms
that are attended with bleedings:that are attended with bleedings:

abortions;abortions;

interrupted fallopian pregnancy;interrupted fallopian pregnancy;

tumors of the uterus.tumors of the uterus.

57. 
TREATMENTTREATMENT

The doctor’s tactics largely The doctor’s tactics largely
depend on the patient’s age.depend on the patient’s age.

58. Juvenile bleedings.Juvenile bleedings.

Conservative treatment (use coagulants, Conservative treatment (use coagulants,
hemostatic agents, stimulants of uterine hemostatic agents, stimulants of uterine
contractility).contractility).

Hormonal haemostasis (“medicamentous Hormonal haemostasis (“medicamentous
curettage” synthetic estrogen-progesteron curettage” synthetic estrogen-progesteron
drugs (logest, yrina, dgaz, ganin) are drugs (logest, yrina, dgaz, ganin) are
prescribed in a dose of 5-6 tablets daily is prescribed in a dose of 5-6 tablets daily is
gradually decreased to 1 tablet per day ( the gradually decreased to 1 tablet per day ( the
total couse of drug administration is 21 total couse of drug administration is 21
days). days).

Diagnostic curettage of the uterine mucosa.Diagnostic curettage of the uterine mucosa.

When bleeding has been arrested, cyclic When bleeding has been arrested, cyclic
hormone therapy is administered for 6 or 9 hormone therapy is administered for 6 or 9
cycles.cycles.

59. In the child-bearing age.In the child-bearing age.

Diagnostic curettage of the uterine mucosa.Diagnostic curettage of the uterine mucosa.

Conservative treatment.Conservative treatment.

Hormonal haemostasis (“medicamen-tous Hormonal haemostasis (“medicamen-tous
curettage” synthetic progestins (norcolut, curettage” synthetic progestins (norcolut,
orgametril, utrogestan, dyphaston) are orgametril, utrogestan, dyphaston) are
prescribed in a dose of 5-6 tablets daily is prescribed in a dose of 5-6 tablets daily is
gradually decreased to 1 tablet per day ( the gradually decreased to 1 tablet per day ( the
total couse of drug administration is 21 days). total couse of drug administration is 21 days).

When bleeding has been arrested, cyclic When bleeding has been arrested, cyclic
hormone therapy is administered for 6 or 9 hormone therapy is administered for 6 or 9
cycles. cycles.

60. Premenopausal and Premenopausal and
menopausal agemenopausal age

Diagnostic curettage of the uterine mucosa.Diagnostic curettage of the uterine mucosa.

Conservative treatment.Conservative treatment.

Hormonal haemostasis (“medicamen-tous Hormonal haemostasis (“medicamen-tous
curettage” synthetic progestins (norcolut, curettage” synthetic progestins (norcolut,
orgametril, utrogestan, dyphaston) are orgametril, utrogestan, dyphaston) are
prescribed in a dose of 5-6 tablets daily is prescribed in a dose of 5-6 tablets daily is
gradually decreased to 1 tablet per day ( the gradually decreased to 1 tablet per day ( the
total couse of drug administration is 21 total couse of drug administration is 21
days).days).

The therapy is directed at regulating the The therapy is directed at regulating the
menstrual function ( in women under 45 menstrual function ( in women under 45
years) or its suppression ( in women over 45 years) or its suppression ( in women over 45
years).years).

61. 
DYSMENORRHOEA DYSMENORRHOEA
(ALGOMENORRHOEA)(ALGOMENORRHOEA)

This term is used to painful This term is used to painful
menstruation.menstruation.

Pain may develop before the Pain may develop before the
onset of menstruation and onset of menstruation and
continue throughout the period of continue throughout the period of
menstrual flow.menstrual flow.

62. 
Sometimes, pain is severe and attended Sometimes, pain is severe and attended
by nausea, vomiting and other by nausea, vomiting and other
disturbances, which reduce the patient’s disturbances, which reduce the patient’s
working capacity.working capacity.

In many cases dysmenorrhoea is just a In many cases dysmenorrhoea is just a
manifestation of systemic diseases. manifestation of systemic diseases.

It may be attributed to retroflexion or It may be attributed to retroflexion or
anteflexion of the uterus, cicatricial anteflexion of the uterus, cicatricial
changes, and narrowing of the cervical changes, and narrowing of the cervical
canal.canal.

63. 
Primary and secondary forms of Primary and secondary forms of
dysmenorrhoea are distinguished.dysmenorrhoea are distinguished.

The formes does not appear to be linked The formes does not appear to be linked
to any organic disease and is congenital.to any organic disease and is congenital.

The latter develops in women with The latter develops in women with
previously normal menstruations.previously normal menstruations.

Secondary dysmenorrhoea may be Secondary dysmenorrhoea may be
related to inflammatory processes, related to inflammatory processes,
endometriosis, and genital tumors.endometriosis, and genital tumors.

64. Treatment.Treatment.

Anti-inflammatory drugs.Anti-inflammatory drugs.

Hormonal drugs.Hormonal drugs.

Surgical treatment.Surgical treatment.

Sedative drugs.Sedative drugs.

Vitamin therapy.Vitamin therapy.