What Goes Around Comes Around Zoulikha Zair 29 th April 2013

Follicular Phase Early Follicular phase Hypothalamus and pituitary free from feedback inhibition FSH and LH have begun to rise, particularly FSH due to lack of inhibin FSH stimulates the granulosa cells LH binds to theca cells Follicles begin to grow Mid follicular phase As follicles grow and develop they secrete more and more oestrogen and inhibin Inhibin has selective inhibition on FSH No more follicles recruited and FSH begins to fall more than LH Oestrogen dominant End of follicular / pre-ovulatory phase Follicles have continued to develop, one becoming dominant Oestrogen levels are rising rapidly POSITIVE FEEDBACK on LH LH SURGE, disrupts mature follicle and releases egg

Luteal Phase – Disrupted follicle forms Corpus Luteum – Corpus Luteum secretes oestrogen and progesterone… levels rise rapidly – LH, FSH, GnRH remain suppressed – Corpus luteum lasts 14 days – Dominated by Progesterone

Categories of Abnormal Bleeding: No bleeding – Amenorrhea Abnormal uterine bleeding – Menorrhagia-heavy and regular – Metrorrhagia-heavy and irregular – Polymenorrhea-frequent – Oligomenorrhea- infrequent – Dysmenorrhea Dysfunctional uterine bleeding – IMB-Intermenstrual bleeding Early pregnancy complications – Pregnancy related 5

Dysmenorrhea Painful periods Prostaglandins- causes peristalsis of tubes 6 Primary Dysmenorrhea No pathology Common in adolescents 60-90% Missed school Rx-NSAIDS, Birth control pills in order to stop the cyclic release of endometrium to stop cramping, time Secondary Dysmenorrhea Due to pathology Middle reproductive years Common eg endometriosis

Absent bleeding - Amenorrhoea Primary – never had menses by age 16 Secondary – ( >3mths) or (>6mths)- texts vary Two categories: Physiological and Pathologic Physiological – Pre-puberty – Pregnancy – Puerperium (3 – 4 weeks after baby is born) – Lactation – Menopause Pathological – Hypothalamus  anorexia/stress/severe systemic illness – Pituitary  tumour/ pituitary infarct – Ovary  dysgenesis/damage/premature ovarian failure – Uterus  absent/scarred (through inflammation) – Cervix / Vagina  present/patent/perforate – Which of the three fundamentals is affected? HPO axis 7

Endometriosis - ectopic endometrial glands and stroma Common condition great variety in symptoms; cyclical – mainly dysmenorrhoea, dyspareunia – irregular menses Hypotheses – retrograde menstruation - metaplasia - iatrogenic association with infertility if disproportion of tubes and oviducts are such that fertility is impaired 8 Endometriosis

Questions