1. Gynaecological disorders
Lecture-3
Presented By
Magdy M. Awny, Ph.D.,
2018/2019

2. B-Secondary (congestive) dysmenorrhea
Common in post-teenage women any time after menarche [typically after 25 year of age]
Causes/Etiology:
Usually secondary to pelvic disorders e.g. Endometriosis, Polyps, fibroid (benign fibro muscular uterine tumors) & adenomyosis uteri
Signs and symptoms:
pelvic or abdominal pain due to venous congestion of pelvis
postcoital pain or bleeding
Dyspareunia
menorrhagia
intermenstrual bleeding
menorrhagia (↑menstrual flow )
intermenstrual bleeding (bleeding in between periods)
Adenomyosis uteri: condition of glandular tissue (endometrium) in the muscle (myometrium)
Or common benign condition of the uterus in which endometrium grows into the myometrium
S & S: menstrual cramp, abdo bloating, heavy period
Ttt: NSAIDs (cramp), levonorgestrel releasing IUD, GnRH analogue (heavy period)or endometrial ablation: invasive procedure that destroy lining of endometrium

3. Secondary dysmenorrhea differs from primary dysmenorrhea in:
Differential diagnosis:
Secondary dysmenorrhea differs from primary dysmenorrhea in:
Item
Primary Dysmenorrhea
Secondary (Dysmenorrhea
Onset
6-12 moths after menarche
Any time after menarche (after 25 year age) pain during 1st one or two cycles
Pelvic pathology
Absent
Present
Pain onset
With the onset of menstrual flow & last 8-72 hrs
Pain occur any time during menstrual cycles with changeable intensity
Symptoms
Headache, thigh, back pain
N,V & D
Dyspareunia, menorrhagia , postcoital pain or bleeding
Response to analgesic & OC
Good
Poor

4. C-Membranous dysmenorrhea:
Management of secondary Dysmenorrhea: depend on the cause
Endometriosis associated dysmenorrhea treated by
Combined oral contraceptive (COCs)
levonorgestrel releasing intrauterine system
gonadotrophin releasing hormone, danazol & progestogens
Progestogens (medroxyprogesterone & gestrinone) →
induce anovulation with amenorrhea so can treat symptoms of
dysmenorrhea in women with endometriosis
C-Membranous dysmenorrhea:
-Rare condition in which large part of endometrium shed as one piece
causing sever pain
-Treatment:- combined or progesterone–only pills

5. Premenstrual syndrome (PMS)
Definition:
-A recurrent luteal-phase condition, characterized by physical, psychological, and
behavioral changes of sufficient severity to result in deterioration of interpersonal
relationships and normal activity.
-It varies between women and resolve around the start of  bleeding.
-when these symptoms are so sever that interfere with daily activities; the condition is
referred to as premenstrual dysphoric disorder [PMDD]…..severe form of PMS
Symptoms of PMS:
Physical
Mastalgia (breast swelling & tenderness),
Back pain, Constipation, diarrhea, H2O retention & Wt gain.
Headache, abdominal cramp, acne, muscle & joint pain
Behavioral
Insomnia, fatigue & food carvings [over eating],
Changes in sexual desire & social withdrawal
Emotional (psychologic)
Anxiety, depression, sadness, auditory hallucination,
Irritability, mood swings, loneliness,
Lack of concentration, anger & confusion.
-A recurrent luteal-phase condition (occurs between ovulation and onset of menstruation),

6. Etiology of PMS: cause is Unkn but many factors are present
Epidemiology: upto 80% of menstruating women experience symptoms of PMS, with
20-30% reporting moderate to severe symptoms
Etiology of PMS: cause is Unkn but many factors are present
Genetic factors
Hormonal changes during cycle:
as S & S of PMS change with hormonal fluctuation and disappear with pregnancy
or menopause
E.g. estrogen ↑in preovulatory phase & ↓at ovulation. & at postovulatory phase
progesterone gradually rise until menstruation occur
Fluctuation in brain serotonin level (↓5HT) → Food craving, Insomnia,
(treated by SSRI) depression, mood swing ,
fatigue, irritability

7. Etiology of PMS:
Low level of VIT B6, E , ↓Mg , Ca+2 and essential fatty acid
↑production of uterine PGs → abdominal cramp, diarrhea &
back, muscle, joint pain
↑prolactin release from pituitary →mastalgia
↑androgen production →acne
↑production of mineralocorticoids → abdominal cramp, bloating,
H2O retention & wt gain
↓endorphin level → pain

8. Diagnosis of PMS: Treatment of PMS: Non drug therapy
Diagnosis depend on presence of at least 5 cyclic symptoms that disappear few days after menstruation
Symptoms start 1-2 weeks before period & disappear at the onset of menstruation
Treatment of PMS:
Non drug therapy
↓fluid & salt intake
 Exercise, reduction of stress
 Enough sleeping
 Avoid alcohol, smoking & caffeine drinks

9. Drug therapy:
1-NSAIDs e.g. naproxen, mefenamic acid to relief abdominal cramp, back pain not mastalgia
2-diuretic [spironolactone]
To ↓H2O retention, abdominal bloating & breast tenderness [mastalgia]
3-Ca (1200 mg/day) →inhibit irritability and abdominal bloating
Mg ( mg/day) →↓fluid retention and abdominal cramp (smooth muscle relaxant effect)
VIT E→↓mastalgia, insomnia, fatigue
VIT B6→↓fluid retention
4-Antidepressant (SSRI) e.g. fluoxetine, paroxetine, citalopram & sertraline
Inhibit neuronal uptake of serotonin →↑its level in brain so treat depression, mood swing

10. 5-Combined oral contraceptive (contains estrogen):
Inhibit ovulation and stabilize hormonal swings →improve physical symptoms
Bloating, headache, mastalgia, abdo.pain
6-Medroxyprogesterone acetate (Depo-Provera®) injection →for sever cases
It cause temporary inhibition of ovulation, but it may worsen some PMS symptoms
e.g. wt gain, headache, depression and ↑ed appetite
7-Danazol:
- Derivative of 17 alpha–ethinyl testosterone with weak androgenic activity
-Act by ↓release of FSH, LH from anterior pituitary →↓ovarian production of
Estrogen, progesterone
.it has anti-estrogenic, anti-progesterogenic effects that help relief many of PMS symptoms
e.g. mastalgia
-Side effects: wt gain, ↓breast size, hirsutism, deepening of voice, ↑libido, liver function

11. 8-GnRH agonists (analogue): Leuprolide, goserelin, histrelin, Nafarelin
-↓ovulation by inhibition of gonadotrophin release [FSH, LH] from pituitary
- They relive physical & behavioral symptoms of PMS
- Prolonged use of GnRH agonists needs combination with “add-back “ therapy
with Estrogen & or progesterone to ↓long term side effect
- Due to their hypoestrogenic effect, they may → atrophic Vaginitis , hot flush and
osteoporosis
a pill that adds back low levels of a hormone without interfering with the effectiveness of the used treatment e.g. leuprolide
9-phytoestrogen and natural progesterone; Derived from licorice

12. Endometriosis Definition: Epidemiology:
The presence of proliferating endometrial tissue outside the uterine cavity, it may occur anywhere in the body but mostly limited to pelvic structures
Epidemiology:
5-15% of all premenopausal women have endometriosis to some degree,
75% of them are between years old

13. Etiology of endometriosis:
Still Unkn but the most widely accepted etiology involve retrograde menstruation
Reverse or backward flow theory:
Backward flow of menstrual fluid along with fallopian tubes in to the abdominal cavity carrying with it shreds of endometrial tissue where they attach and grow.
This misplaced tissue responds to the hormonal changes of the menstrual cycle by building up & breaking down (shedding) like the endometrium →internal bleeding. Blood from this misplaced tissue has no outlet so → swelling & inflammation of surrounding tissue and scar tissue may surround the affected area in which bleeding occur & may develop to lesion or growths

14. Other etiologies include: -Over production of ovarian estrogen
- immune system stimulate cells that secrete factors which increase endometrial
tissue growth
Location of endometriosis, mostly in ovary and may found in
Fallopian tubes, lining of the pelvic cavity
Intestine and rectum
Bladder and uterus
Vagina, vulva and outer surface of uterus
Risk factors of endometriosis:
Uterine abnormality
Genetically
Family history (1st degree relative e.g.
mother with the disease)
Birth of first time after the age of 30 years

15. Signs and symptoms of endometriosis:
- Excessive menstrual cramp in lower abdomen or back (2ry dysmenorrhea)
- Dyspareunia
- Painful bowel movement and dysuria during menstruation
- Menorrhagia
- Infertility [20-45%], fatigue, nausea, diarrhea and constipation
Diagnosis of endometriosis:
1-Medical and family history
2-physical examination of pelvis
3-laparoscopy [transabdominal endoscopic examination of the pelvic region]
To determine size, extent & location of endometrial growths
4-Biopsy to determine if cancer or abnormal cells are present or not ...< 1% of cases
5-CAT or CT scan (computer –assisted tomography), MRI and ultrasound….all create an image on the internal organs.

16. Management of endometriosis
Non drug therapy: Rest, relaxation, worm bath, regular exercise & avoid constipation
Drug therapy:
Analgesic e.g. NSAIDs for pelvic pain
B. Hormonal therapy: to interrupt the ovarian cycle so ↓or eliminate the hormonal stimulation
of endometriosis
1-Combined oral contraceptive: prevent ovulation and ↓menstrual flow
2-progestins e.g. norethisterone 5 mg/day to decrease symptoms
They are used to induce pseudopregnancy, are taken for 6-9 months
3-danazol: as above
4-GnRH agonists e.g. Leuprolide
They ↓hormone production [estrogen, progesterone] by inhibition of
Gonadotrophin release [FSH, LH] from anterior Pituitary i.e. Medical
menopause (pseudomenopause) that result in anovulation, amenorrhea, and
atrophy of endometrium and endometrial implants
NB:- Clomiphene citrate 50mg tab
1x1x5 from 5th day
↑Gonadotropin release→ Improve Ovulation

17. C. Surgical intervention
-Laparotomy; surgical opening of abdominal wall to remove! displaced endometrium
-Laparoscopy: laparoscope inserted to abdominal wall to see & remove endometrial
growth
-Hysterectomy: surgical removal of uterus
-Hysterosalpingoectomy: surgical removal of uterus and fallopian tubes
-Hystero-ovariectomy: surgical removal of uterus & ovaries
-Laser surgery to remove displaced endometrial tissues