Gynecology
Cases
I. Anatomy and Physiology
Anatomy
- Uterine Layers
- Endometrial: columnar epithelium and connective tissue
- Basal layer and functional layer (sheds)
- Myometrium: smooth muscle cells
- Perimetrium: epithelial cells enveloping the uterus
Menstrual Cycle
GnRH
-> FSH and LH
-> primary follicles turn into antral follicles
(containing granulosa cells)
-> estrogen secretion
-> FSH receptor stimulation and follicle
growth
-> positive feedback on ant. Pituitary gland +
estrogen increase
-> LH secretion
-> growth and maturation
-> FSH and LH surge
-> converts estrogen producing cells to
progesterone producing cells
-> estrogen drop => ovulation
-> granulosa and theca cells form luteal cells
-> progesterone + inhibin (negative feedback
on progesterone)
-> corpus luteum degeneration =>
menstruation
Postmenopausal Hormones
,Sperm Production and Fertilisation
- Sperm production
- Hypothalamus: GnRH production -> pituitary production of FSH, LH
- Pituitary
- FSH -> androgen binding protein on Sertoli cells to produce sperm and
support blood-testis barrier
- LH -> stimulates Leydig cells for testosterone production and secretion
- Testes: spermatogonial stem cell development via testosterone stimulation
- Epididymis: maturation ; sperm move up the tube and are stored until ejaculation
- Vas deferens: muscular tube transporting the sperm
- Spermatic cord = vas deferens + nerves + blood vessels
- Seminal vesicles: seminal fluid including fructose (provides ATP for mobility)
- Ejaculatory duct
- Prostate gland: adds alkaline fluid to seminal fluid
- Urethra: join ejaculatory duct from bladder ; continues until glans penis
- Sperm cell: life-death = 60 days
II. Menstrual Cycle Disorders
1. Menorrhagia
- Definition: prolonged menstrual periods and/or excessive bleeding
- Excessive bleeding: lasts more than 7 days, loss of over 80 mL of blood
- Average woman loses 30 mL of blood
- Can be accompanied by pain
- Concerning Factors
- Soaking through a pad/tampon every 1-2 hours for several hours
- Heavy periods regularly lasting 10 or more days
- Bleeding between periods or during pregnancy
- Pathology: often no causative reason
- Pregnancy or miscarriage
- Hormonal imbalance: common around menarche and menopause
- Ovulation problems: anovulation leads to stopped progesterone production which
can cause heavy bleeding
, - Uterine fibroids (leiomyomas): increased menstrual loss if protruding into central
cavity -> increase endometrial surface area
- Uterine polyps: small benign growths or other structural abnormalities in the
uterus causing bleeding
- Endometriosis: extension of endometrial tissue outside the uterus trying to shed
-> painful and abnormal bleeding
- Adenomyosis: endometrial tissue develops within muscle layers of the uterus ->
painful and heavy bleeding
- Infectious: uterine or cervical infection ; PID
- Cancer (painless): uterine, ovarian, cervical, endometrial ; bleeding can be
excessive, irregular, in between periods, postmenopausal
- Coagulation defects: rare ; painless ; normal coagulation must occur to limit and
eventually stop the blood flow
- Medication: anticoagulants anti-inflammatory medications, IUDs
- Other: systemic lupus erythematosus, diabetes, PID, cirrhosis, thyroid disorders
2. Amenorrhea
- Definition: absence of menstruation
- 1ry: no menstruation by the age of 16
- 2ry: periods stop for at least 3 months
- Pathology
- Normal: pregnancy, breastfeeding, hormonal contraception, perimenopause,
adolescence
- 1ry:
- Delayed puberty: failure of ovarian development ; genetic factor
- Congenital genital tract abnormalities
- 2ry:
- Stress: physical/emotional stress blocks release of LH causing temporary
amenorrhea
- Weight loss, eating disorders: extreme weight loss and reduced fat stores
cause hypothyroidism and hypercortisolism in turn impairing gonadotropin
hormones (low estrogen)
- Athletic training: linked to stress and weight loss or use of anabolic
steroids
- Polycystic ovarian syndrome (PCOS): ovarian overproduction of
androgens (testosterone)
- Premature ovarian failure (POF): early depletion of follicles before age 40
leading to low estrogen and premature menopause ; causes infertility
- Structural problems: scarring/structural problems in the uterus prevents
menstrual flow
- Hyperprolactinemia: reduced gonadotropin hormones inhibiting ovulation
- Pituitary tumors: low estrogen levels
- Endometriosis: see above
- Other: epilepsy, thyroid problems, celiac sprue, metabolic syndrome,
Cushing’s disease
, 3. Oligomenorrhea
- Definition: menstruation occurs more than 35 days apart
- Common in early adolescence (hormonal changes/puberty) ; can occur in healthy
adult women
- Flow can vary
- Pathology: same as amenorrhea
4. Other
- Polymenorrhea (frequency)
- Definition: cycles with intervals of 21 days or fewer
- Metrorrhagia (bleeding)
- Definition: bleeding occurring at irregular intervals with variable amounts
occurring between periods or unrelated to periods
- Menometrorrhagia (bleeding)
- Definition: heavy and prolonged bleeding occurring at irregular intervals occurring
at the time of menstruation or between menstruations
- Dysfunctional uterine bleeding (bleeding)
- Definition: abnormal uterine bleeding referring to extra or excessive bleeding
caused by hormonal problems
- Usually occurs at the start of menstruation or at perimenopause
I. Clinical Features
- Risk factors
- Age: menarche at a younger age increases risk for pain, longer periods, longer
menstrual cycles ; perimenopause can cause oligomenorrhea or menorrhagia
- Weight: overweight/underweight
- Menstrual cycles/flow: associated with pain
- Pregnancy history:
- High number of pregnancies: increases risk of menorrhagia
- No pregnancies: higher risk of dysmenorrhea
- Smoking: increases risk for heavier periods
- Stress: blocks LH causing temporary amenorrhea
- Diagnosis
- History taking: menstrual cycle patterns, medical conditions, family history,
history of pelvic pain, use of medications, diet history (includes caffeine, alcohol,
smoking), past/present contraceptive use, stress, sexual history
- Physical examination: vaginal examination
- Extra
Cases
I. Anatomy and Physiology
Anatomy
- Uterine Layers
- Endometrial: columnar epithelium and connective tissue
- Basal layer and functional layer (sheds)
- Myometrium: smooth muscle cells
- Perimetrium: epithelial cells enveloping the uterus
Menstrual Cycle
GnRH
-> FSH and LH
-> primary follicles turn into antral follicles
(containing granulosa cells)
-> estrogen secretion
-> FSH receptor stimulation and follicle
growth
-> positive feedback on ant. Pituitary gland +
estrogen increase
-> LH secretion
-> growth and maturation
-> FSH and LH surge
-> converts estrogen producing cells to
progesterone producing cells
-> estrogen drop => ovulation
-> granulosa and theca cells form luteal cells
-> progesterone + inhibin (negative feedback
on progesterone)
-> corpus luteum degeneration =>
menstruation
Postmenopausal Hormones
,Sperm Production and Fertilisation
- Sperm production
- Hypothalamus: GnRH production -> pituitary production of FSH, LH
- Pituitary
- FSH -> androgen binding protein on Sertoli cells to produce sperm and
support blood-testis barrier
- LH -> stimulates Leydig cells for testosterone production and secretion
- Testes: spermatogonial stem cell development via testosterone stimulation
- Epididymis: maturation ; sperm move up the tube and are stored until ejaculation
- Vas deferens: muscular tube transporting the sperm
- Spermatic cord = vas deferens + nerves + blood vessels
- Seminal vesicles: seminal fluid including fructose (provides ATP for mobility)
- Ejaculatory duct
- Prostate gland: adds alkaline fluid to seminal fluid
- Urethra: join ejaculatory duct from bladder ; continues until glans penis
- Sperm cell: life-death = 60 days
II. Menstrual Cycle Disorders
1. Menorrhagia
- Definition: prolonged menstrual periods and/or excessive bleeding
- Excessive bleeding: lasts more than 7 days, loss of over 80 mL of blood
- Average woman loses 30 mL of blood
- Can be accompanied by pain
- Concerning Factors
- Soaking through a pad/tampon every 1-2 hours for several hours
- Heavy periods regularly lasting 10 or more days
- Bleeding between periods or during pregnancy
- Pathology: often no causative reason
- Pregnancy or miscarriage
- Hormonal imbalance: common around menarche and menopause
- Ovulation problems: anovulation leads to stopped progesterone production which
can cause heavy bleeding
, - Uterine fibroids (leiomyomas): increased menstrual loss if protruding into central
cavity -> increase endometrial surface area
- Uterine polyps: small benign growths or other structural abnormalities in the
uterus causing bleeding
- Endometriosis: extension of endometrial tissue outside the uterus trying to shed
-> painful and abnormal bleeding
- Adenomyosis: endometrial tissue develops within muscle layers of the uterus ->
painful and heavy bleeding
- Infectious: uterine or cervical infection ; PID
- Cancer (painless): uterine, ovarian, cervical, endometrial ; bleeding can be
excessive, irregular, in between periods, postmenopausal
- Coagulation defects: rare ; painless ; normal coagulation must occur to limit and
eventually stop the blood flow
- Medication: anticoagulants anti-inflammatory medications, IUDs
- Other: systemic lupus erythematosus, diabetes, PID, cirrhosis, thyroid disorders
2. Amenorrhea
- Definition: absence of menstruation
- 1ry: no menstruation by the age of 16
- 2ry: periods stop for at least 3 months
- Pathology
- Normal: pregnancy, breastfeeding, hormonal contraception, perimenopause,
adolescence
- 1ry:
- Delayed puberty: failure of ovarian development ; genetic factor
- Congenital genital tract abnormalities
- 2ry:
- Stress: physical/emotional stress blocks release of LH causing temporary
amenorrhea
- Weight loss, eating disorders: extreme weight loss and reduced fat stores
cause hypothyroidism and hypercortisolism in turn impairing gonadotropin
hormones (low estrogen)
- Athletic training: linked to stress and weight loss or use of anabolic
steroids
- Polycystic ovarian syndrome (PCOS): ovarian overproduction of
androgens (testosterone)
- Premature ovarian failure (POF): early depletion of follicles before age 40
leading to low estrogen and premature menopause ; causes infertility
- Structural problems: scarring/structural problems in the uterus prevents
menstrual flow
- Hyperprolactinemia: reduced gonadotropin hormones inhibiting ovulation
- Pituitary tumors: low estrogen levels
- Endometriosis: see above
- Other: epilepsy, thyroid problems, celiac sprue, metabolic syndrome,
Cushing’s disease
, 3. Oligomenorrhea
- Definition: menstruation occurs more than 35 days apart
- Common in early adolescence (hormonal changes/puberty) ; can occur in healthy
adult women
- Flow can vary
- Pathology: same as amenorrhea
4. Other
- Polymenorrhea (frequency)
- Definition: cycles with intervals of 21 days or fewer
- Metrorrhagia (bleeding)
- Definition: bleeding occurring at irregular intervals with variable amounts
occurring between periods or unrelated to periods
- Menometrorrhagia (bleeding)
- Definition: heavy and prolonged bleeding occurring at irregular intervals occurring
at the time of menstruation or between menstruations
- Dysfunctional uterine bleeding (bleeding)
- Definition: abnormal uterine bleeding referring to extra or excessive bleeding
caused by hormonal problems
- Usually occurs at the start of menstruation or at perimenopause
I. Clinical Features
- Risk factors
- Age: menarche at a younger age increases risk for pain, longer periods, longer
menstrual cycles ; perimenopause can cause oligomenorrhea or menorrhagia
- Weight: overweight/underweight
- Menstrual cycles/flow: associated with pain
- Pregnancy history:
- High number of pregnancies: increases risk of menorrhagia
- No pregnancies: higher risk of dysmenorrhea
- Smoking: increases risk for heavier periods
- Stress: blocks LH causing temporary amenorrhea
- Diagnosis
- History taking: menstrual cycle patterns, medical conditions, family history,
history of pelvic pain, use of medications, diet history (includes caffeine, alcohol,
smoking), past/present contraceptive use, stress, sexual history
- Physical examination: vaginal examination
- Extra
