Disorders of function of reproductive system. 1. Rationale. In the structure gynecologic diseases disorders of menstruation occurs in 20% of cases. Different disorders of menstruation result in high working disability, development of neuropsychic complications, invalidism of women. These complications claim for complex approach and joint treatment by physicians of different specialities – gynecologist, endocrinologist, neurologist and others. 1. Objectives (are described in the terminology of professional activity, taking into account the system of classification of the objectives of the respective levels of cognitive, emotional and psychomotor spheres): -To analyze the results of main methods of functional diagnostics in gynecology -To explain The levels of regulation of woman`s genital functions -To suggest tactics of management of patients with hormonal imbalance of female reproductive system. -To classify mestrual disordes (irregularities) -To interpret the results of laboratory and instrumental examinations of the cervix, endometrium, ovaries, depending with fazes of MC, the clinical and biochemical, hormonal studies of blood, results of colpocytologycal examination -To draw a diagram scheme of menstrual cycle --To make the analysis of the methods of functional diagnosis in gynecology -To make up the models of clinical cases with various hormanal pathology in women of reproductive and premenopausal age. 3. The basic level of expertise, skills, abilities, required for learning the topic (interdisciplinary integration ) The name of the previous Acquired skills disciplines Normal Anatomy Structure of female genital organs. Topography of abdominal organs and pelvic organs. Histology Histological structure of the cervix, vulva and endometrium in normal and in pathological conditions. Notmal Physiology Physiological changes occurring in the hypothalamic- pituitary-ovarian system of women and target organs of the sex hormones action at different ages. Pathological Physiology Hormonal changes in the body during the menstrual cycle and disorders of the microbiota of the female reproductive system. Pharmacology Groups of medications that affect the function of the hypothalamus, pituitary gland, ovaries, adrenal glands; mechanism of pharmacological action of hormonal, hemostatic, anti-inflammatory, antiviral drugs. 4. Tasks for independent work in preparation for the lesson and in class. 4.1. The list of the major terms, parameters, characteristics to be acquired by a student to be prepared for the lesson The term Definition Basic levels of V level is suprahypothalamic cerebral structures. menstruation regulation IV level — hypothalamus and physical stages of Ш level — anterior pituitary. their establishment. II level — ovaries. I level — target organs (uterus, vagina and breasts). Biologic action of sex luteonizing hormone (LH) hormones, hypophysis prolactin hormones and releasing follicle-stimulating hormone (FSH) hormones. estrogens progesterone - Ovarian cycle An ovarian cycle consists of two phases. The first one —follicular phase, the second — luteal phase. Uterine cycle the endometrial lining of the uterus builds up under the influence of increasing levels of estrogen (labeled as estradiol in the image) There are four main stages of the endometrial cycle: desquamation that is mens- truation, regeneration, proliferation, and secretion phases. Menstrual cycle is complex of complicated biological processes in all organism of women, witch characterized cyclical changes in all reproductive organs and provided conception and pregnancy Ovulation Ovulation is the process when the membrane of mature follicle is ruptured and oocyte is expelled from the follicle amenorrhea • absence of menses in adult women within 6 months. hypermenorrhea • a excessive amount of blood, more than 100- 150 ml polymenorrhea • — menses' duration is 7-12 days • — a combination of local pain and general algodysmenorrhea state disturbance dysfunctional uterine acyclic uterine bleeding that is not associated bleedings. with menstrual cycle. FIGO classification of is now being increasingly used for categorising cause: ‘PALM-COEIN’ causes: Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy,Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified The ‘PALM’ are assessed visually (imaging and histopathology) and the ‘COEIN’ are non- structural. 4.2 Theoretical questions for the lesson: 1. Classification of the menstrual function disorders. 2. Amenorrhea. 3. Dysfunctional uterine bleeding. Classification. Methods of diagnostic and treatment. 4. Juvenile uterine bleeding. Etiology, symptomatic diagnosis and treatment. 5. Postmenopausal uterine bleeding. Etiology< symptomatic, diagnosis and treatment. 6. Algodismenorrhea. Symptomatic, diagnosis and treatment. 7. Neuroendocrine syndromes in gynecology. 4.3 Practical activities (tasks) to be performed on the lesson: To perform gynecological examination (bivalve vaginal speculum, bimanual, rectal, rectovaginal). To analyze the results of main methods of functional diagnostics in gynecology To suggest tactics of management of patients with hormonal imbalance of female reproductive system. To classify mestrual disordes (irregularities) To interpret the results of laboratory and instrumental examinations of the cervix, endometrium, ovaries, depending with fazes of MC, the clinical and biochemical, hormonal studies of blood, results of colpocytologycal examination To draw a diagram scheme of menstrual cycle To make up the models of clinical cases with various hormanal pathology in women of reproductive and premenopausal age. 4.4 Topic content Disorders of function of reproductive system. 1. Amenorrhea. 1.1. Primary amenorrhea. 1.1.1. Primary amenorrhea with no sexual development: - gonadal dysgenesis (Shereshevsky–Turner syndrome, Swayer syndrome); - testicular feminization (Morris syndrome). 1.1.2. Primary amenorrhea with sexual development delay: - resistant ovary syndrome (in case it arises in the prepubertal period); - hypogonadotropic hypogonadism. 1.1.3. Primary amenorrhea without sexual maldevelopments: - Maldevelopments of the vagina and uterus (uterine and vaginal aplasia – Rokitansky–Kuestner syndrome; atresia of the hymen, vagina, and cervical canal of uterus). 1.2. Secondary amenorrhea: - hypogonadotropic hypogonadism; - hypergonadotropic hypogonadism; - emotional amenorrhea; - weight loss amenorrhea; - Asherman’s syndrome (intrauterine synechias as a consequence of traumatic injuries of the uterus). 2. Hyperprolactinemia. 3. Dysfunctional bleedings. 3.1. Ovulatory bleedings. 3.2. Anovulatory bleedings: - dysfunctional bleedings of puberty (juvenile); - dysfunctional bleedings of the reproductive period; - dysfunctional bleedings of the premenopausal period. 4. Neuroendocrine syndromes (the most widespread): - premenstrual syndrome; - postcastration syndrome; - climacteric syndrome; - postnatal obesity syndrome; - polycystic ovary syndrome; - adrenogenital syndrome; - Sheehan’s syndrome. 5. Endometriosis. 3.2. Amenorrhea Amenorrhea is the absence of menstruations during 6 months and longer in women aged 16–45 years. The incidence of amenorrhea in population among women of childbearing age makes approximately 3.5 %, and in the structure of reproductive system disorders – 10–15 %. There are differentiated physiological (the absence of menstruations till the pubertal period, during pregnancy, lactation, and in the postmenopause) and pathological types of amenorrhea. The etiology of pathological amenorrhea is very diverse. It is a symptom of a gynecological and extragenital pathology, may be primary and secondary: primary amenorrhea is the absence of menstruations at the age older than 16 years; secondary amenorrhea is the absence of menstruations during 6 months and longer after a period of regular and irregular menstruations. Amenorrhea is considered secondary even if there is a history of one menstruation only. If the interval between the episodes of bloody discharge makes less than half a year, the state is considered a hypomenstrual syndrome, a variety of which is the so-called spaniomenorrhea – menstruations take place 2–3 times a year. Besides, there are singled out true and false types of amenorrhea. The reasons for false amenorrhea are: atresia of the virginal membrane, vagina, cervical canal, and transversal membrane of the vagina. This is accompanied by cyclic changes in the hypothalamo-pituitary-ovarian system and uterus, but the outlet of the menstrual blood is blocked. This leads to menstrual blood accumulation in the upper genital tract with the formation of hematocolpos and hematometra accompanied by pain syndrome. Pathological amenorrhea is also classified depending on the level of affection of a certain part of the reproductive system. According to this there are differentiated hypothalamic-pituitary, ovarian, and uterine forms of amenorrhea, and also amenorrhea conditioned by a pathology of the adrenal glands, thyroid gland, and the presence of extragenital diseases. Primary Amenorrhea Primary amenorrhea is observed much less frequently than the secondary one and makes 8–10 % in the structure of amenorrhea. Primary amenorrhea is more frequently combined with other signs of sexual development delay (SDD), less frequently it arises at all the signs of sexual development preserved. Therefore there are singled out two forms of primary amenorrhea: - with a derangement of sexual development (SDD, hermaphroditism); - without sexual development disorders.