Topic: Disorders of the menstrual cycle. Neuroendocrine syndromes in gynecology icon

Topic: Disorders of the menstrual cycle. Neuroendocrine syndromes in gynecology

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Topic: Disorders of the menstrual cycle. Neuroendocrine syndromes in gynecology.

  1. Topicality: disorders of the menstrual cycle constitute 20% in the structure of gynecological diseases. Various kinds of disoderes of the menstrual function lead to a high loss of ability to work development of neuropsychic complications, disability of women. These complications require complex approach and combined treatment of doctors of several specialities- gynecologists, endocrinologists, neuropathologists, etc. That’s why,study of this pathology is of a great importance for doctors of any speciality.

  2. Number of hours: 4

  3. Educational objectives:

    1. To know:

  1. Classification of disorders of the menstrual cycle.

  2. Classification of amenorrhea.

  3. Additional methods of examination of amenorrhoea.

  4. Pathogenesis, diagnostics and treatment of primary amenorrhoea.

  5. Pathogenesis, clinical signs, diagnostics, treatment and prevention of various forms of secondary amenorrhoea.

  6. Pathogenesis, clinical signs, diagnostics and treatment of hyperprolactinemia.

  7. Causes and pathogenesis of dysfunctional uterine bleeding (DUB).

  8. Classification of DUB by age and character of disorders of the menstrual cycle.

  9. Clinical manifestation and diagnostics of various kinds of DUB.

  10. Methods of treatment of DUB.

  11. Kinds of hormonal hemostasis.

  12. Indications and contraindications for the use of estrogens and hestagens.

  13. Synthetic progestins, androgens.

  14. Spa treatment of DUB.

  15. Etiology and pathogenesis of neuroendocrine syndromes.

  16. Clinical signs and diagnostic methods of neuroendocrine syndromes.

  17. Modern principles of treatment of neuroendocrine syndromes.

3.3. To be able to:

1. Collect general and gynecological anamnesis, perform general and gynecological examination.

2. Make up algorithms of clinical- laboratory examination to determine level of lesion in the system hypothalamus-hypophysis-ovaries-organs-targets in case of amenorrhoae.

3. Estimate the data of functional diagnostic tests, laboratory data and make up the diagnosis of amenorrhoea.

4. Perform differentiative diagnostics of various forms of pathologic amenorrhoea.

5. Substantiate pathogenetic treatment of primary amenorrhoea and various forms of secondary amenorrhoea.

6. Perform differentiation diagnostics of functional and organic hyperprolactinemia.

7. Prescribe treatment of hyperprolactinemia.

8. Perform differentiation diagnostics of uterine bleeding connected with disorders of hormonal function of the ovaries, interruption of pregnancy and malignant diseases of the uterine.

9. Make diagnosis of disorders of the menstrual cycle.

10. Substantiate pathogenetic and symptomatic treatment of various kinds of DUB.

11. Prescribe medicines for hormonal hemostasis depending on age of the patient.



Regulation of menstrual function is an extraordinarily complicated and intricate neurohumoral process, violation of which at any level (CNS — hypothalamus — hypophisis — ovaries — uterus) causes disorders of menstrual cycle in that or other form.

Causes giving rise to menstrual function disorders, are nervous and mental affections, stresses, psychic traumas, sexual infantilism, serious and protracted chronic diseases, chronic intoxications, feeding violations (exhaustion or obesity), endocrine diseases, gynecological diseases.


Amenorrhea — absence of menses. Violation of menses rhythm:

  • opsomenorrhea — menses come extremely rarely: in 6-8 weeks

  • spaniomenorrhea — the extremely long menstrual cycle, menses come 2-4 times per year

  • proiomenorrhea (tachimenorrhoea) — shortened menstrual cycle, menses come in 21 days

Change of blood amount, that exudes during menses:

  • hypermenorrhea — a excessive amount of blood, more than 100-150 ml

  • hypomenorrhea — reduced amount of blood, less than 50 ml Abnormal menses' duration:

  • polymenorrhea — menses' duration is 7-12 days

  • oligomenorrhea — menses duration is less than 2 days Painful menses:

  • algomenorrhea — pain during menses in genital organs region

  • dysmenorrhea — general disturbances during menses (headache, nausea, anorexia, raised irritability)

  • algodysmenorrhea — a combination of local pain and general state distur­bance

Menorrhagia—the cyclic uterine bleeding, associated with menstrual cycle, lasting more than 12 days.

Methrorrhagia — acyclic uterine bleeding that is not associated with menstrual cycle.

There are distinguished hypomenstrual syndrome (opsomenorrhea, oligo­menorrhea, hypomenorrhea) and the hypermenstrual syndrome (proiomenorrhea, hypermenorrhea, polymenorrhea).

According to the woman's age the bleeding is classified:

  • in child age and in period of pubescence —juvenile

  • in women of puberty age — bleeding of reproductive or genital period

  • in climacteric period — climacteric bleeding

According to recurrence ovulative (cyclic, diphasic) disorders of menstrual cycle and anovulative (monophased).


Amenorrhea — absence of menses in adult women within 6 months. Amenorrhea is not an independent disease, but a symptom of many diseases, causing disorders of menstrual function regulation on different levels.

Forms of amenorrhea:

Genuine—absence of cyclic changes in women's organism, most frequently associated with acute insufficiency of sexual hormones.

Falce amenorrhea (cryptomenorrhea — latent menses) — absence of mens­trual blood excretion because of cyclic changes presence in organism. False ame­norrhea is a clinical sign of genital organs development abnormalities — athresia of hymen or vagina, when blood, having no exit, is accumulated in vagina, uterus and uterine tubes.

Primary amenorrhea is the absence of menstrual function from puberty age.

Secondary amenorrhea is the suppression of menstrual function in woman who has menstruated before.

Physiological amenorrhea is absence of menses before puberty period, during pregnancy and lactation, in menopause period.

^ The pathological amenorrhea can be provoked by many causes, especially by general state changes, most frequently by endocrine diseases.

There are different forms of pathological amenorrhea: hypothalamic, pituitary, ovarian and uterine ones according to the level of menstrual function regulation disturbance.

^ The hypothalamic amenorrhea

Psychogenic amenorrhea appears as a result of stress situations and psychic traumas ("student's" amenorrhoea during exams especially, amenorrhea of war period). Excessive secretion of Corticotropin within stress blocks production of releasing hormones by hypothalamus. The production of Lutropin and Folitro-pin is inhibited, the maturing of follicles is stopped, the cyclic changes in uterus regress. Atrophic changes in sexual organs at short duration of disease are absent or expressed insignificantly.

Treatment Menstrual cycle is mostly spontaneously restored after stress factors managing. If amenorrhea continues, therapy is performed by two stages:

I stage. Psychotherapy, balanced feeding are indicated, physical and mentaloverload must be avoided. Drug therapy: sedative remedies are applied — extractof Valerianne, 1-2 tab. per day and Novopassitum 2-3 times per day, Vitamin E,100 mg per day for 20 days, Ascorbic acid 0,15 g/day, Folic acid.

^ Physiotherapy to be applied: the endonasal electrophoresis with 2% vitamin В solution, jugular-facial galvanisation with 0,25% Novocain solution, 2% Sodium bromide solution.

II stage. At absence of menses after 2-3 months of treatment Thyroidin0,05 g per day during 4-5 days and vitamin E are prescribed.

If psychogenic amenorrhea is combined with genital infantilism, hormone therapy is prescribed for stimulation of uterus growth and development of secondary sexual signs.

^ Amenorrhea at false pregnancy appears in women, who are eager or very afraid to become pregnant. Nausea, morning vomiting (probable pregnancy signs, that arise as an auto-suggestion influence), swelling of breasts, some enlarging and softening of uterus can appear. Biological reactions for pregnancy are negative. At US examination fetus in uterus is not found.

^ Amenorrhea at nervous anorexia is found in girls and young women with non-stabile nervous system in period of pubescence, at nervous or physical overload, as a result of irrational diets, directed on becoming thin, at uncontrolled using of remedies, that reduce appetite. Typical is body mass loss, hypotension, hypoglycemia.

Treatment consists of sufficient feeding and prescribing of light sedative remedies.

^ Amenorrhea attached to adiposogenital dystrophy (Pehrants-Babinsky-Frelikh syndrome) develops in period of pubescence. Obesity with deposition of adipose tissue on thighs, abdomen, face, growth delay, hypoplasia of genitalia and intellect reduction are typical.

Etiology is a tumor or trauma of hypothalamic region. Disease can start after neuroinfection, epidemic parotitis, flu. Secretion of Luliberin, Folitropin and Lutropin decreases. It causes the hypophysis-ovaries system dysfunction and finaly it leads to genitals hypoplasia.

Diagnosis is based on clinical data. During gynecological examination absence of hairity on external genitals is found, or it is slightly expressed, vagina is narrow, uterus is considerably reduced in size.

Laboratory research expresses great FSH, LH, estrogens and Pregnandione lowering. In vaginal smear the intermediate cells prevail. There are 30-40% of basal and parabasal cells. Superficial cells are solitary. Basic metabolism is decreased.

If disease is caused by tumor of pituitary body then dilation of turkish saddle is visualized on X-ray report. Rise of intracranial pressure, headache, symptoms of visual nerves compression appear. Unlike the Lorence-Moon-Barde-Bidle syndrome, intellect is not affected in such patients, or it is insignificantly lowered.

Treatment At tumular etiology the treatment consists of ablation of tumor or in X-ray therapy. After operation replacement hormonal therapy is used.

^ Amenorrhea at the Lorence-Moon-Barde-Bidle syndrome (hereditary diencephal-retinal degeneration with autosome-recessive type of inheritance). Clinical symptoms are like the clinic of the Pekhrant-Babinsky-Frelix syndrome. However, the main peculiarity of the patients is presence of drastic mental retard-ness (oligophreny), defects of development (polydactily, syndactily, pigmental retinitis). The patients have poor eyesight (sometimes total blindness), lowering of hearing or total deafness, skull anomalies, excessive development of fatty cellular tissue.

Treatment For body weight lowering a diet with limitation of fats, carbo­hydrates, liquid, and also medical physical training are recommended. Medicinal therapy includes using of Thyreoidin — 0,05-0,2 g per day for 4-5 days per month. The patients take the gonadothropic hormones — choriogonin 500 IU for 2-4 days per month. Afterwards cyclic hormone therapy is held at first by Estrogens (Microfollinum 0,01 mg 2 times a day) or Folliculin 5-10 th. units daily during 20 days. If uterine enlargement and appearance of secondary sexual signs begins in 3-6 months, hormone therapy by estrogens and Progesterone should be applied.

^ Amenorrhea at the Morghani-Stuart syndrome. It is rarely found. In pathogeny one can find affection of hypothalamo-pituitary allotment as a result of procrastination of Calcium salts in the region of turkish saddle (internal frontal hyperostosis).

Clinical features: headache, paroxysms of convulsions, psychic violations, obesity, virilism.

Treatment is symptomatic.

Amenorrhea at persistent lactation syndrome (the Kiary-Frommel syndrome). In disease basis is lesion of hypothalamic centres, producing Prolactin inhibiting releasing-factor. It causes the rise of Prolactin secretion that inhibits FSH production in its turn. The consequence of this is lowering of estrogens amount, amenorrhea, and further — atrophy of external and internal genitalia. More frequently the disease appears in postnatal period (after pathological delivery) or after abortion.

The basic symptom is: galactorrhea that begins after delivery. High level of Prolactin in patient causes persistent lactation. After stopping of baby feeding milk secretion continues. There is hypertrophy of breasts with expressed vascular pattern. Genital organs atrophy appears. Disorders of carbohydrate and fatty metabolism are developed, arterial pressure becomes unsteady.

Diagnosis is based on symptomatics. For exclusion of the pituitary tumors X-ray examination of turkish saddle, axial computered tomography, determination of acuity and field of vision is made.

During determining of sexual hormones amount in blood, there is found rising of Prolactin level, lowering of Folitropin level. The amount of estrogens in blood and urine decrease. 17-ketosteroids excretion is not changed.

Tests of functional diagnostics show monophase basal temperature: 36,5-36,8°C. Pupil and fern symptoms are negative during the whole cycle.

Cytological research of vaginal smear allows to find lowering of estrogens amount. In smear there are found out up to 50% parabasal cells, KI is lower than 5%.

Treatment. Hormone therapy, directed on inhibiting of lactation and regulation of menstrual function is applied. The most effective remedy for treatment of galactorrhea is a Prolactin inhibitor. Patient should take 2,5-5 mg of Parlodel per day during 6 months. For lowering of Prolactin level also grinded Camphora is used — 0,1 g three times a day orally, or 20% solution — 2 ml twice a day; Bromcamphora — 0,25-0,5 g 2-3 times a day orally.

^ The pituitary amenorrhea

Amenorrhea at pituitary nanism. Disease develops in prenatal period or during the first months of life due to infectious diseases or traumatic damages of anterior part of pituitary. Insufficiency of all its hormones including somatotropin appears as a result.

Treatment mainly is in an endocrinologist's competence. One should begin treatment in childhood with growth stimulation. Further replacement hormonal therapy is indicated.

^ Amenorrhea at gigantism and acromegalia. Diseases are caused by Somatotropin hyperproduction, production of gonadothropic hormones is decreased. Amenorrhea has a secondary character.

Treatment At pituitary tumors rhoentgenotherapy is indicated. For patients with gigantism estrogen therapy for stopping of excessive growth is prescribed.

^ Amenorrhea at Itsenko-Kushing's disease is caused by excessive produc­tion of Corticothopin. The disease develops at age of 20-40. The earliest symp­tom is body weight increasing with expansion of fatty tissue predominantly on face, neck and trunk. Skin and skeleton changes appear, arterial blood pressure rises, cardiosclerosis and nephrosclerosis develop. There develops osteoporosis due to bones' demineralization and hirsutism (hair grows on unusual for a woman places — face, breasts, abdomen). The tension stripes, eruption of acne vulgaris type, hyperpigmentation of external genitals, appear on skin.

Treatment is provided by endocrinologist. It consists of Khloditan — the inhibitor of adrenals' cortex hormones synthesis prescribing. If there is no effect there is performed rhoentgenotherapy of hypothalamus and pituitary region or adrenalectomy with the following replacement therapy by Prednisolone.

^ Amenorrhea at Shikhane syndrome develops after pathological delivery or septic diseases and is associated with hemorrhage into pituitary and following necrosis of its anterior, and sometimes also posterior part. Necrosis size determines severity of disease course.

Clinic. In woman after recent difficult delivery there appears headache, giddiness, weakness and anorexia. Later asthenia, body weight decreasing, ame­norrhea and mixedema develops. Head and pubis grow bald. Arterial blood pres­sure and body temperature decrease. Difficult form of the Shikhane's syndrome manifests in panhypopityitarism. It is a deficit of gonadothropic hormones that causes persistent amenorrhea, hypotrophy of genitals and breasts; deficiency of TTH — mixedema, growing bald, somnolence, worsening of memory; ACTH — hypotension, adynamy, weakness, intensive skin pigmentation. Typical is per­sistent anemia, that is resistant to treatment.

Diagnosis. In anamnesis there is septic shock or bleeding during delivery or abortion. Hormonal investigation data shows different degree of gonadotropins, TTH, ACTH decreasing in blood, in urine a level of 17-CS and 17-OCS is also decreased. There is hypoglycemia and a hypoglycemic type of sugar curve at glucose loading.

Treatment is directed to improve general patient's state. Food rich in calories and vitamins are used. At expressed asthenia anabolic hormones are taken. Replacement therapy is using of Prednisolon 5 mg per day during 2-3 weeks once for 3 months, Thyreoidin, Estrogens and Progesterone in cycles. For patients after 40 years androgens are prescribed, taking into account their high anabolic effect: Methyltestosteronum 5 mg per day. Vitamin therapy is recommended. Vitamin В, С, РР, biostimulators are used.

^ The ovarian amenorrhea

The causes of ovarian amenorrhea are: congenital gonades' dysgenesia (disease appears as a result of sexual chromosomes anomaly), the Shereshevsky-Terner's syndrome and syndrome of scleropolycystic ovaries (the Shtein-Levental syndrome).

Shereshevsky-Terner's syndrome is a complex of genetic defects, connec­ted with chromosomes anomaly (one X-chromosome is absent), that causes tissue inability to development and damage mesodermal rudiments of muscular and osseous tissue in embryonic period. Ovarian tissue also suffers due to harmful influence at the period of genital glands' differentiation period, that causes death of secretory epithelium and its replacement by connective tissue.

After birth children have low body mass, later they grow slowly. They growth does not exceed 140 cm. Special body building is typical. These children have disproportionate tubby thorax, short neck with wing-like folds, squint, ptosis, the ears are lowly placed and have wrong shape. There appear plural bone structure violations — osteoporosis. Degenerative-dystrophic changes and changes in vertebrae bodies and shape of the tubular bones also appear.

In puberty period secondary sexual signs do not appear. Breasts are underdeveloped. Hairity is absent completely or insignificant, external genital organs, vagina, uterus are abruptly underdeveloped (fig. 68). Primary amenorrhea is typical. Menses appear in patients on condition that treatment was begun in time.

Diagnosis. Research of chromosomes shows a wide spectrum of chromosome anomalies: XO/XX; XO/XXX; XO/XX/ Mosaicism is also typical.

During laboratory investigation of hormones amount they determine considerable increasing of FSH level. Level of 17-CS excretion is rather decreased.

The US examination shows the expressed hypoplasy of uterus or presence of connective tissue instead of internal genitals. Sometimes uterus is absent at all.

In vaginal smear during cytological research basal and parabasal cells are found.

Treatment In childhood cure is directed foremost to growth stimulation. Therapy with hormones is recommended not earlier than at the age of 15, because

earlier beginning of cure with estrogens causes closing of epiphysis zones of the bones and a complete growth stop.

The aim of hormones replacement therapy (at first only with estrogens) is the forming of figure for woman's type and correction of body disproportion. To improve hormones' reception Thyreoidin 0,1 mg and Folic acid, 10-20 mg daily 20 days per month are prescribed. At the same time a patient takes Ethynilestradiol or Microfollin in dose of 0,05-0,1 mg for 20 days, then makes a 10 days' inter­val. Therapy continues for 3-4 months and causes the development of secondary sexual signs and menstrual-like reaction. Then 3-phase combined estrogen-gestagen medicines are taken according a scheme: Microfollin "forte" 0,05 mg per day from the 1st till the 20st day of artificially formed menstrual cycle and Pregnin 0,01 g three times a day, the 21st till the 26th day.

^ The polycystic ovarian syndrome (the Shtein-Levental's syndrome, POS) is a clinical complex of symptoms, that is characterized by enlargening and cystic changes of ovaries and disorders of menstrual cycle. Endocrine disturbances manifest with increasing of LH, Androstendiol and Testosterone level. Contem­porary gynecological endocrinology conception about pathogenesis of polycystic ovaries' syndrome is considerably broadened. A typical form with ovarian hyperandrogeny, that was described by Shtein and Levental, a central form with expressed violations of hypothalamic-hypophysar system and a combined form, caused by ovarian and adrenal hyperandrogeny are differed.

For typical POS form a break of sexual hormones' biosynthesis processes in ovary tissue is the main characteristic. As a result of the broken hormonal effect. Albuminous ovarian membrane thickens, with fibrosis of underlying layers. Theca interna is also thickened. In subcortical layer there are found many cysts and athresed follicles.

Clinical course of the polycystic ovaries' syndrome manifests in period of pubescence, sometimes later, at the age of 20-30 years. Basic symptoms are amenorrhea (hypomenorrhea), hirsutism, obesity, infertility, enlarged and cysti-cally altered ovaries. Disturbances of menstrual cycle are expressed in form of anovulatory cycles, hypomenstrual syndrome, amenorrhea, more rare — as uterine bleeding. Due to unovulation infertility appears. Hirsutism is one of permanent signs of polycystic ovaries' syndrome and is expressed in hair growing on face, on extremities, on anterior abdominal wall and around nipples. Obesity is found approximately in 1/3 of patients and is combined with signs of hypothalamic-pituitary dysfunction: tension stripes on abdominal wall and thighs, increasing of intracranial pressure.

Diagnosis. During bimanual examination that is found uterus of normal size or slightly reduced. Ovaries are enlarged, dense and mobile. In patients with obesity it is hard to estimate an ovaries size by palpation, that's why additional

methods of investigation are necessary. The US examination gives a possibility to find a degree of ovaries enlargening and many cysts of different size

Processing laboratory research on amount of hormones, a LH concentration can vary from insignificantly increased significantly, a FSH level does not exceed norm. Excretion of 17-CS is on the top norm or it is just increased.

Tests of functional diagnostics: basal temperature is monophased (36,5-36,8°C). Pupil and fern symptoms are negative. These are the signs of anovulative cycle. Cytological investigation of vaginal discharge allows to find lowering of estrogens amount.

For specification of diagnosis and differential diagnostics with other pa­thological processes in ovaries it is necessery to perform laparoscopy, the biopsy of ovaries when there are indications.

Treatment. Basic principles of polycistic ovaries' syndrome therapy are: conservative treatment, directed to normalize menstrual cycle induce, ovulation and renew reproductive function with medicinal methods. Surgical treatment takes into consideration the newest achievements of endoscopic surgery.

^ The aim of conservative therapy at primary polycystosis (scleropolycystosis) is to normalize the function of hypothalamus-pituitary-ovarian system, steroids biosynthesis and mechanism of ovulation, that must induce restoring of the repro­ductive function. A method of treatment is determined according to the clinical and pathogenetic variant of the disease, patient's age, continuation and dysfunction degree in reproductive system, expressence of morphological changes in ovaries and uterus.

^ Treatment effectiveness criteria: restoring of menstrual function and ovulation, coming of pregnancy, decreasing of hirsutism.

Hormone therapy, directed to normalization of menstrual function is necessary to control permanently with use of functional diagnostics tests, and with determination of sexual hormones' level that allow to diagnose ovulation.

If polycistic ovaries'syndrome becomes apparent in period of pubescence, one should begin therapy with restorative and vitamin therapy. It is undesirable to prescribe hormonal therapy for girls befdre 18. For normalization of sexual hormones metabolism they prescribe Glutamin acid 1 tabl. twice a day, Calcium pantothenat 1 tabl. 2 times a day from the first day of menstraal cycle (at ame­norrhea the first day is considered to be the first day of a remedy taking) during 20 days, Galascorbin 1 tabl. 2 times a day, vitamin E once (in the evening) from the 14th day of a cycle during 15 days. Such therapy is taken for 3-6 months. If menstrual cycle is not normalized, a therapy by 2-component gestagen-estrogen preparations with minimum amount of sexual hormones: preparations prescribe in dose of 1 tabl. per day during 21 days (cure starts to on 5th day of menstrual cycle) should be applied, after a 7-day break the course should be repeated, therapy lasts 3-4 months.

They use Clostylbegit (Clomipheni citras, Clomid, Tamoxyphene (according to the scheme) during 3 months. At the end of each cycle after reception of the last dose of the medicine 500-1500IU of Choriogonin (ChG) for 3-5 days is prescribed.

At the therapy of secondary polycistic ovaries on the background of adrenal hyperandrogeny it is recommended to combine glucocorticoids with Clomiphen.

For hirsutism treatment they use Cytotheroni acetate 100-200 mg per day from the 5th till the 14th day of menstrual cycle. When moderate hirsutism the combined estrogen-gestagen preparation with antiandrogenic action "Diane-35" 1 tabl. from the 5th till the 26th cycle day are prescribed. Effect comes commonly in 10-12 months of the reception.

^ Surgical treatment is the most effective method of renewing of menstraal and generative function. Depending on influence on ovaries there are following types of operative treatment: laparotomy with a wedge-shaped ovaries resection, demedullation, decapsulation, decortication. Perspective is the method of endo­scopic ovaries' resection, electropuncture (pierce cystic formations with needle-shaped electrode), thermocauterization (after ovaries fixation thermocauter is inserted into the gland tissue till the immersion into the medullar layer in 6-10 places), laser vaporization (they use carbon surgical laser, make evaporation of all cystous formations under the video monitor control). Advantages of endoscopic interventions are the absence of adlusions possibility for, ovaries and uterine tubes visualization exclusion of other causes of infertility and possibility of making accretions dissection in small pelvis, decreasing of bleeding risk during operation.

Patients' rehabilitation after operation includes:

  • systematic menses calendar keeping

  • measuring of basal temperature during 3-6 months

  • making colpocytological research at 7,11,14,21,25th cycle day, at absence of menses they take 5 smears with 5-day interval

  • control examination in 3 months after operation and later on control examination every three months during the first year, during the following year— twice a year, then — once a year

  • if a woman becomes pregnant she must come for consultation and regi­stration as soon as possible

  • if pregnancy does not come in 6 months after operation, prescribing of combined hormone therapy is indicated. A patient takes Norcolut from the 16th till the 26th day of menstrual cycle during 2 months. Then stimulation of the ovulation by Clomiphen is performed

^ The uterine form of amenorrhea

The uterine form of amenorrhea can be primary (as a result of uterus deve­lopment anomalies) and secondary, that appears as a result of inflammatory pro­cess with formation of synechyas (accretions) in uterine cavity; endometrium traumas during abortion or diagnostic currettage, when a structure of basal layer is damaged, after the tuberculosis of endomethrium or Iodine introduction into uterus. Tests of functional diagnostics inform about ovaries' functions. During hysteroscopy there is found thinning or atrophy of endomethrium and presence of synechias in uterine cavity.

Treatment Dissection of synechias in uterine cavity is performed as endoscopic operation. 2-3 courses of cyclic hormone therapy allow to restore menstrual function in the majority of patients, however the reproductive function is restored rarely.


A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women's genitals, interrupted pregnancy or systemic diseases of the organism.

The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset juvenile bleeding (at child age and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. Most frequently the dysfunctional uterine bleeding appear in young women during the formation of menstrual and reproductive function. In early reproductive phase as a damaging factor are frequently the situations, connected with mental and physical overload. Chronic stress and diseases of adaptation are the pathological background on which the lesions of hormonal status develop.

In women of reproductive age the basic cause of dysfunctional uterine bleeding are inflammatory diseases. Late reproductive phase, or premenopause, comes in women at the age over 35. At this age even moderate irritants, which earlier were not the reasons of menstrual function disorders, can become starting mechanism for development of cyclic system activity dysfunction.

Disease etiology is associated with unfavourable affects of environment, psychic stresses, lesions of the ovaries' and other endocrine glands function.

Dysfunction of hypothalamus-pituitary-ovaries-uterus system cause violation of follicle maturing. Depending on the fact that ovulation comes or not, the bleeding can be ovulative and anovulative.

Classification of dysfunctional uterine bleeding according to pathogeneses:

I. Ovulative (two-phased) according to the type of:

  • hypoestrogeny

  • hypogestageny

  • hyperestrogeny

II. Anovulative (monophased) according to the type of:

  • hypoestrogeny

  • hyperestrogeny

According to onset time: cyclic (those, that come in term of next menses, but differ from it with amount of lost blood and duration); non-cyclic (appear out of menses or continue with interruptions during all the cycle).

According to patient's age: juvenile, of reproductive age, climacteric, menopausal bleeding.

^ Non-ovulate uterine bleeding

Follicle atresia is a disorder of menstrual cycle, that manifests in cyclic uterine bleedings through regular time intervals, but ovulations are absent. Follicle begins its development, reaches some maturity degree, but ovulation does not come, Luteal body does not appear, follicle undergoes reverse development. There is no regular hormones' excretion (oestrogens-progesteron), secretory changes do not come in endometrium. Disease is followed by hypoestrogeny.

Clinic. Menses loose regular rhythm, intensity and duration. In response to follicle atresia and decreasing of hormones amount, in 8-16 days after bleeding onset menstrual-like reaction comes. Its mechanism is connected with blood transsudation from superficial endometrium layer vessels, where hemorrhages and regions of necrosis appear. Absence of ovulation causes infertility, that is frequently a basic patients' complaint. The anovulate cycles can alternate with ovulate ones.

Diagnostics. For making diagnosis a continued observation of a woman and research of functional diagnostics tests indexes are necessary. Basal temperature is monophased, line is beneath 37°, the "fern" and "pupil" phenomena are weakly expressed or they are absent at all even in the middle of menstrual cycle. The colpocytological examination shows a moderate or insignificant satu­ration of organism with estrogens. The histological investigation proves that there are no secretory transformations of endometrium, uterine mucous membrane is in proliferation phase with tissue oedema.

Ovarian cycle

Days of menstrual cycle



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