Abnormal bleeding

* Pregnancy (abortion ectopic abruption previa)

* Fat/DM/ chronic anovulation/ Heavy & lengthy bleeding in above age 40 ::::
endometrial cancer
* Frequent bleeding : remove mechanical fibroids/iud
* Inconsistent anovulatory bleeding : regularised with BCP
* Heavy or lengthy bleeding : regularised/stopped with BCP week-off/continuously or
disrupted with DMPA
* Lengthy bleeding denuded endometrium : thicken with strong estrogen & stop
bleeding with mild estrogen & harden with progesterone for 10days

Absent mullerian structures (uterus,vagina)

* Primary amenorrhoea since no outflow tract

* MULLERIAN AGENESIS normal estrogen & testosterone levels of OVARY causes normal
breast dev & pubic-axillary hair. Renal abnormalities.
* ANDROGEN INSENSITIVITY male level testosterone from Y chromosome gonad cause
normal Breasts from peripheral conversion to estrogen but scant hair due to
defective androgen receptor.

Hyperandrogenism causes

* PCOS
* Hyperprolactinemia (galactorrhea)
* Late onset Congenital Adrenal hyperplasia (17 -OH progesterone)hypOOtension
* Adrenal tumor (DHEA-S)
* Ovarian sertoli-leydig tumor (testosterone)
* Thyroid disorder (goitre)
* Cushing syndrome (hypertension buffalo hump)

Sertoli-leydig cell tumor of ovary

* Increased 5 alpha reductase & decreased SHB globulin

* DHT causes hirsutism after conversion of High levels of unbound testosterone from
ovary

Risks

* High Unopposed estrogen PCOS : endometrial cancer

* Low estrogen : osteoporosis
* Cervical stenosis : endometriosis
* Y chromosome gonad : Neoplasia
* Fat/DM/ chronic anovulation/ Heavy & lengthy bleeding in above age 40 ::::
endometrial cancer

PCOS

* Anovulatory signs : Chronic menometrorrhagia since menarche & string of pearls

* Insidious hirsutism from hyperandrogenism
* Excess estrogen
* Metabolic syndrome

Hirsutism

* RAPID a/w virilization in tumors of adrenal (abdominal mass) or ovary sertoli-

leydig (adnexal mass)
* INSIDIOUS a/w acne in PCOS

Rx

* GnRH agonists -central cause of Precocious puberty

* HRT -sheehan
* Operative hysteroscopy -asherman
* Surgical removal of Y chromosome gonads -neoplastic risk with 46xy gonadal
dysgenesis & androgen insensitivity.
* Clomiphene - induce ovulation in PCOS desiring pregnancy.
* OCP - regulate menses in PCOS don't desire pregnancy
* Weight loss & OCP + Spironolactone : hyperandrogenism ( lower ovarian androgen &
elevate SHBglobulin, peripheral antagonism)

Puberty. Menarche.

* 4 stages: breast THElarche, hair PUBarche-ADRENarche, GROWTH spurt, MENarche.

* Estrogen causes BREAST. Androgen cause HAIR.
* No breast dev in estrogen deficiency. No hair in androgen deficiency.
* #DELAYED PUBERTY Primary amenorrhoea with infantile Breasts are seen in
hyper/hypo gonadotropic HYPOGONADISM. HYPER cause is ovary, evaluated by
karyotyping (gonadal dysgenesis). HYPO cause is CNS, evaluated by h&p& hormonal
levels.
* Primary amenorrhoea with breast dev are seen in mullerian agenesis and androgen
insensitivity. Differentiated by scant hair in androgen insensitivity.
* # PRECOCIOUS PUBERTY Peripheral causes are ovarian granulosa cell tumors &
adrenal tumors. MCC central cause is idiopathic where the patient is initially tall
but later shorter than that of his age. Others brain tumors, hydrocephalus, head
trauma require brain imaging & bone age.
*

Pituitary adenoma

* Galactorrhea without hyperprolactinemia. OBSERVE if estrogen/menses normal(low

risk). MRI if (high risk) low estrogen/menses.
* Galactorrhea with hyperprolactinemia. Doesn't desire pregnancy despite normal
estrogen, Rx PERIODS PROGESTIN WITHDRAWL Desires pregnancy but low estrogen, Rx DA
AGONIST BROMOCRIPTINE CABERGOLINE.
* Surgery in case of Noncompliance to medical Rx or macro adenoma.

Lactation

* Production -Prolactin
* Oozing out -oxytocin
* Galactorrhea -nonpeuperal watery/milky (fat droplets on smear. No pus blood). B/l
spontaneous/expressed

Pituitary

During pregnancy hypertrophies without proportional increase in vascular supply.

Unlike posterior (ADH,oxytocin), anterior Pituitary (Prolactin, TSH, FSH LH) lacks
direct blood supply so is vulnerable to ischemic necrosis

Secondary amenorrhoea

* ASHERMAN Hormonally unresponsive due to Adhesions+-sclerosis obliterating

endometrial cavity from Trauma (mechanical d&c/conization, infectious, radiation)
to basal endometrium in a recently pregnant(postpartum/miscarriage) uterus/cervix
* SHEEHAN hypo hormonal state due to anterior Pituitary necrosis from ischemic
damage during postpartum hemorrhage and hypotension

Contrasting definitions

* Menses.Amenorrhoea . Primary = by 16 age. Secondary = 6mon or more.

* Secondary sexual characters.Puberty = tanner stage 3 by 14 age. Precocious = 2SD
from mean
* Gonadotropins = FSH LH differentiate cause [NORMAL PUBERTY: elevated if ovary,
lowered if CNS] [PRECOCIOUS PUBERTY: lowered in peripheral cause, elevated to
reproductive levels in central cause]. GONADAL = ovarian estrogen.
* Hyperandrogenism = hirsutism acne virilization
* RARE Virilization = clitoromegaly voice-deepening temporal-balding muscled male
habitus
* Metabolic syndrome = glucose intolerance, hyperlipedimia, hypertension, central
obesity.

Clinical presentations

* Delayed puberty -infantile genetalia and primary amenorrhoea.

* Hyperprolactinemia -galactorrhea
* Ovarian failure -hot flushes
* Amenorrhoea -hormonally unresponsive endometrium
* Hypothalamic dysfunction -poor nutrition, eating disorders, excess exercise,
chronic illness, stress.
* Primary hypothyroidism -goitre
* Pituitary adenoma -galactorrhoea, headache, peripheral visual field defect
bitemporal hemianopsia
* Craniopharyngioma-neurologic deficits
* Kallmann syndrome - anosmia

Hormone induction tests

* PROGESTIN bleeds if estrogen thickened

* ESTROGEN followed by PROGESTIN bleeds if hormonal. Not if outflow tract problem

Infertility treatments

* Clomiphene for inducing ovulation

* Laproscopy for uterine and tubal factors
* ICSI & IVF for male factor
* Restoration of pelvic anatomy in endometriosis
* IU insemination for cervical factor

Endometriosis in fertile vs infertile

* Incidence 5% vs 40%
* Fecundity 20% vs 10%

Fecundity
Probability of live birth in a given monthly cycle.
= around 20%
Accounts to 90% after 12months

Infertility

* Primary (never)
* Secondary (1yr inability)

Infertility diagnosis : Uterine fibroids and salphingitis

* HSGram (radiologic dye)

* SIS (saline infused vaginal US)
* HScopy (endoscope is gold standard)

Ovarian factor seen in 3 conditions

* Polycystic ovarian syndrome

* Premature ovarian failure
* Hypothalamic or Pituitary disorder

Ovulation signs

* Regular menses
* Biphasic BBT (followed by 0.5F rise for 10-12days)
* Day 21 serum progesterone
* Prior LH surge
* Day3 FSH
* Anti-mullerian hormone
* US: Diminished follicle size
* Cul de sac fluid

Fertility factors

* Ovulation (biphasic bbt & regular menses)

* Uterine (fibroids-menorrhagia)
* Tubal (H/O STDs chlamydial/gonococcal)
* Male (semen analysis including those who previously conceived children)
* Endometriosis (3D dysmenorrhoea dyspareunia dyschezia)
* (rare)cervical viscid thick (h/o cryotherapy)

HAO outflow tract

* Hypothalamus (pulsatile GnRH TRH)

* TRH acts on Anterior Pituitary to produce TSH and Prolactin. GnRH increases FSH
LH.
* Gonadotropins TSH Prolactin Thyroid hormones have inverse feedback on
hypothalamus.
* Ovary releases estrogen progesterone.
* Menses represent Patent outflow tract
* normal HAO with Ovulatory cycles have Biphasic Basal body temperature and regular
menses
*