1.04 Gyne Amenorrhea Dr. DeLeon 2021

Gynecology Amenorrhea
AY 2021-2022 Renna Cristina B. de Leon, MD, FPOGS, FIFEPAG

1st Shifting 09/10/2021
OUTLINE II. Puberty

I. HPG axis
II. Review on Puberty ● FACTORS AFFECTING TIMING OF ONSET OF PUBERTY
III. Amenorrhea → Genetics
A. Primary Amenorrhea → Nutritional state
B. Secondary Amenorrhea ▪ Malnutrition (such as with anorexia nervosa or starvation)
.
LEARNING OUTCOMES
→ General health ②
is known to delay the onset of puberty
▪ Onset of puberty and menarche is determined by the body

 Review on puberty
 Define amenorrhea ⇐ composition than the total body weight.
 Explain the pathophysiology and identify the etiologies of @
▪ Thus the ratio of fat to both total body weight and lean
Amenorrhea body weight is probably the most relevant factor that
 Describe associated symptoms and physical exam findings determines the time of onset of puberty and menstruation
 Discuss the steps in the evaluation and initial management
 Describe the consequences if it is untreated → Geographic location
•
and not the critical body weight of 48 kgs.
▪ Studies have noted that those living in higher altitudes

I. Hypothalamic-Pituitary-Gonadal Axis usually have delayed puberty
→ Exposure to light
▪ Those with less exposure to light (especially the blind)
have faster puberty.
▪ According to studies, it is mainly due to the melatonin
composition of these patients as well as the circadian
rhythms.
→ Psychological state
▪ Those who are stressed or has psychological problems
usually would have delayed onset of puberty as well as
menarche.
→ Exposure to estrogenic endocrine – disrupting
chemicals
▪ Leptin, Grelin
→ Absence of a father in the home
▪ According to studies, absence of the father causes faster
puberty in the patients
→ Influence of light
-0g
● Breast budding – 1st recognized pubertal change
● Accelerated growth (Growth spurt) – 1st sign of puberty
● Hypothalamic-Pituitary-Gonadal/Ovarian Axis
● Gonadotropin Releasing Hormone (GnRH) is secreted by the
roof
hypothalamus.
→ GnRH will signal the anterior pituitary gland to secrete:
⑤
▪ LH
▪ FSH
→ LH and FSH act and signals the ovaries to release sex Pubertal changes
steroid hormones: First sign of pubertal change – breast budding
▪ Estrogen 
▪ Progesterone Pubarche (2nd) – presence of axillary and pubic hair
→ Estrogen and progesterone can then cause a positive or✓ 
Peak Growth velocity
anterior pituitary.
,
negative feedback on the hypothalamus, as well as the

Menarche – happens usually after 2-3 years after breast
budding.
sml Excelsus 2023 1 of 9

Comparison of Girls and Boys Pubertal Development ● WHAT HAPPENS IN NORMAL MENSTRUATION?
(sorry couldn’t find a clearer picture)

→ Any dysfunction in the HPO axis  Amenorrhea
Breast Tanner Staging

III. Amenorrhea
● Amenorrhea is defined as the absence of menstrual bleeding
and may be:
→ Primary Amenorrhea (never occurring)
▪ Defined as the absence of menses in a woman who has
never menstruated by the age of 15 years old.
▪ Girls who have not menstruated within 5 years of breast
development (thelarche) – should occur at around 13 yo
•←=•
▪ Incidence: 0.1%
→ Secondary Amenorrhea
(Cessation sometime after initiation)
▪ Defined as the absence of menses for an arbitrary period
(usually 6 – 12 months).
▪ Incidence: 0.7% - 3%
− Higher in women younger than 25 years old and those
with prior history of menstrual irregularity.
● Cryptomenorrhea is caused by anatomic disorders interfering

Pubic Hair Tanner Staging with the outflow of menses but are actually menstruating.
→ Also called Pseudo- or False Amenorrhea
→ Such as Imperforate hymen, Transverse vaginal septum, or
Distal vaginal atresia
● WHO Classification of Women (outside the US)

Classification
Type I low estrogen levels
Low FSH
Normal Prolactin (PRL) levels
NO or without CNS lesions.
Type II Normal estrogen status
Normal FSH and Prolactin levels
Type III Low estrogen levels with High FSH level
- DENOTES OVARIAN FAILURE
● What we use, based on anatomy

→ Type 1 – 4 – 2 – 3
▪ Order from most common to least
Type Breast Development Uterus
I - + Most common
II + - 3rd most common
III - - Least common
IV + + 2nd most common
Gyne Amenorrhea 2 of 9
A. PRIMARY AMENORRHEA → FSH levels are consistently elevated
→ All individuals with primary amenorrhea and plasma FSH
● Causes of Amenorrhea.
→ Useful to group causes on the basis of whether secondary levels higher than 40 mIU/mL have no functioning ovarian
f
sexual characteristics (breasts) and female internal genitalia follicles in the gonadal tissue.
f
(uterus) are present or absent
→ TURNER SYNDROME (45,X Anomalies)
▪ DIAGNOSIS: Presence of characteristic features in
phenotypic females + complete or partial absence of the
second chromosome, with or without cell like mosaicism
− 45,X karyotype
000
-
- − Mosaic karyotypes (i.e., 45,X/46, XX ; 45,X/46,XY)
- -
▪ Presents with:
− Primary amenorrhea with absent breast development
− Short stature (<60 inches in height)
IE
− Webbing of the neck
Mu − Small hyperconvex fingernails
− Short fourth metacarpal
F ⑮ − Cubitus valgus
− Slow growth
− Lymphedema
− Large cystic hygromas of the neck at birth
me
− Multiple
W
pigmented nevi
− Disorders of the heart, kidneys (most common
horseshoe), and great vessels (most commonly
coarctation of the aorta)
v N EssentialV
− Diabetes Mellitus, Thyroid disorders,
hypertension, and other autoimmune disorders.
a
▪ Normal intelligence
−a
a
Unusual cognitive defect
− Inability to appreciate the shapes and relations of
-
objects with respect to one another (i.e. space-form
blindness)
- -
▪ Small ring X chromosome  increased risk of mental
men
retardation
▪ PE in adults:
N
− Short stature
I
− Do not develop breasts at puberty
− Some pubic or axillary hair (sparse)
Type I – Breasts Absent and Uterus Present

A● Most Common
● Either the result of a primary ovarian disorder or a CNS
hypothalamic-pituitary abnormality, which provides the normal
signal to the ovary.
● No ovarian estrogen production either to a primary ovarian
disorder or CNS abnormality
A. Gonadal Failure (Hypergonadotropic Hypogonadism)

→ Includes:
▪ 45,X (Turner syndrome)
I
▪ 46,X, abnormal X (e.g., short- or long-arm deletion)
▪ Mosaicism (e.g., X/XX, X/XX,XXX)
Ov
▪ 46,XX or 46,XY pure gonadal dysgenesis
-
▪ 17α-hydroxylase deficiency with 46,XX
of
▪ In these patients, in place of the >
ovaries there’s a band of
I fibrous tissue called the gonadal streak.
DB
→ Failure of gonadal development is the most common cause
- -
→ Caused By: = O
of primary amenorrhea – occurs in 50% with symptoms ▪ Breast development does not occur because of the low
circulating E2 levels. X
f▪ Mostly a chromosomal disorder or deletion of all or part of
an X chromosome (Turner’s syndrome). 45x
− The negative hypothalamic-pituitary action of estrogen
and inhibin is not present, gonadotropin levels are
▪ Sometimes caused by another genetic defect and, markedly elevated, with FSH levels being higher
▪ Rarely, 17α-hydroxylase deficiency. than LH.
− Estrogen is not necessary for müllerian duct = Given after the patient -first experiences
-
vaginal
I
-
development or wolffian duct regression, so the internal bleeding
and external genitalia are phenotypically female. = After 6 to 12 months of unopposed estrogen use
if the patient has not yet had any bleeding.
▪ Diagnosis of Turner syndrome:
-
− History and PE a o Dose of estrogen in increased slowly over 1 to 2
a− Karyotype is indicated  to eliminate the possibility of ->
years until the patient is taking about twice as much
the presence of any portion of a Y chromosome
⑧
estrogen as the amount administered to
o 12% risk of a gonadoblastoma postmenopausal women.
= Treatment: laparoscopic prophypactic
gonadodectomy − Counseling
00
= Precursors to germ cell malignancies, such as
Dysgerminomas (most common), Teratomas, → PURE GONADAL DYSGENESIS (46, XX and 46 XY with
Embryonal Carcinomas, or Endodermal Sinus Gonadal Streaks)
Tumors. ▪ If gonadal development is absent in the presence of
O46,XX
-
▪ Work up in Turner’s Syndrome:

− Cardiovascular tests
-
▪ Normal stature and phenotype
Ve
▪ Absence of secondary sexual characteristics
-
− Renal Function test ▪ Presence of Primary amenorrhea
− IVP
− Renal Ultrasound → 46,XY GONADAL DYSGENESIS
− Thyroid function tests ▪ Result of an abnormal testis in utero
− FBS a
▪ Called as Swyer syndrome
me
▪ Gonadectomy should be performed.
▪ Treatment of Turner’s Syndrome:
-A
O
− Increase the final adult height
→ 17 - Hydroxylase Deficiency with 46,XX Karyotype
o Use of exogenous GH
= Recombinant human GH: - average height gain -▪ Rare
▪ Hypernatremia and Hypokalemia
 4 to 16 cm
I
-
#
-
− Decreased cortisol  elevated ACTH

1. Early initiation of therapy (between 2 – 8
r years of age) − Elevated mineralocorticoid levels  hypertension and
2. Gradually increasing the dose I hypokalemia
v
3. Continuing treatment for a mean of 7
years. N
− Elevated serum progesterone levels
− Treatment: Cortisol administration
 Weakly GH 0.375 mg/kg divided in
7 doses
m → Central Nervous System – Hypothalamic – Pituitary
A
 Bone average ≥ 14 years and Disorders
-v
growth velocity < 2 cm/year Central Nervous System Lesions

 Girls > 8 years of age or with ▪ Congenital (e.g., stenosis of aqueduct, absence of sellar
extreme short stature floor)
 Higher doses of GH PLUS ▪ Acquired (tumors)
 Oxandrolone − Non-prolactin-secreting pituitary tumors
( </= 0.5 mg/kg/day ) (Chromophobe adenomas)
<
A − Craniopharyngiomas (most common)
Higher doses is not given
because it can cause
V
▪ Work-Up: Computed tomography (CT) scanning /
Virilization and Rapid Magnetic Resonance Imaging (MRI) of the hypothalamic-
skeletal maturation pituitary region
N N
− Gonadal Steroid Treatment B. Hypothalamic failure secondary to inadequate GnRH
o Promote sexual maturation release
= Initiate exogenous estrogen A
N
= Patient is psychologically ready
→ Inadequate GnRH release (Hypogonadotropic
mem Hypogonadism)
= 12 – 13 years of age → Includes:
= -
After - -
GH therapy was administered for several
a years N
▪ Insufficient GnRH secretion because of neurotransmitter
defect
***Low-dose estrogen alone (0.025 mg per day ▪ Inadequate GnRH synthesis (Kallmann syndrome)
&
transdermal estradiol or 0.3 – 0.625 mg conjugated ▪ Congenital anatomic defect in central nervous system
estrogens orally each day) ▪ CNS neoplasm (craniopharyngioma)
o Progestins (5 – 10 mg medroxyprogesterone → HYPOTHALAMIC FAILURE

>
acetate or 200 mg micronized progesterone orally
-
↓ r
▪ Insufficient GnRH synthesis
▪ CNS neurotransmitter defect
for 12 – 14 days every 1 to 2 months)  added to
a
- -
prevent endometrial hyperplasia
A
→ KALLMAN SYNDROME N
→ Male karyotype
O
I
▪ Defect of KAL gene (xp 22-3) → Elevated gonadotropin levels; Testosterone levels normal or
▪ Normal height A below-normal female range wor
▪ Greater wingspan-to-height ratio (increase growth of long
bones) → Differential Diagnosis:
▪ Triad: ▪ 17- Hydroxylase Deficiency – testes present but lack
− Altered spatial orientation abilities enzyme to synthesize sex steroids  female external
K − Anosmia
− Amenorrhea
genitalia  female internal genitalia regress  low
testosterone levels  male internal genitalia do not
develop
C. Pituitary failure ▪ 17,20 – Desmolase Deficiency - lack of sex steroid
→ Includes: synthesis
▪ Isolated gonadotropin insufficiency (thalassemia major, ▪ Agonadism – Vanishing Testes Syndrome
V
retinitis pigmentosa)
▪ Pituitary neoplasia (chromophobe adenoma)
− Have no gonads present
VI
▪ Mumps, encephalitis
a B. Congenital Absence of the Uterus
▪ Newborn kernicterus
I N
→ Uterine Agenesis, Uterovaginal Agenesis, Mayer-Rokitansky-
r
▪ Prepubertal hypothyroidism
O
Kuster-Hauser Syndrome
→ Isolated Gonadotropin Deficiency (Pituitary Disease) O
→ 2nd most frequent cause
O
▪ Do not respond to GnRH O
→ Normal ovaries – regular cyclic ovulation
-
⑧
▪ Associated disorders: → Normal endocrine function
− Thalassemia major (with iron deposits in the pituitary) → Normal breast and6 0
pubic and axillary hair development
---
− Retinitis pigmentosa → Shortened or absent vagina
- -
− Prepubertal hypothyroidism → Renal abnormalities

a
− Kernicterus → Cardiac abnormalities

-
− Mumps encephalitis
C
Type III – Absent Breast and Uterine Development
O
Type II – Breast Development Present and Uterus NBreast and uterus
● O present
⑧
Absent ● 2nd largest category
● Two disorders: ● 25% - Hyperprolactinemia and Prolactinomas
→ Androgen Resistance ● 75% - Profiles similar to those with secondary amenorrhea
G
▪ Genetically inherited disorder
→ Congenital Absence of the Uterus Primary Amenorrhea with Absent Endometrium
fur
▪ Accident of development and does not have an ● Rare condition
established pattern of inheritance. ● Endocrine function normal
of and fallopian
● Normal uterus, ovaries, f tubes
A. Androgen Resistance ( Testicular Feminization ) ● Endometrium absent?? – genetic defect
→/Rare (translocation between chromosome 4 and 20)
N
→ Genetically transmitted disorder
Te
in which androgen receptor
rums
synthesis or action does not occur DIFFERENTIAL DIAGNOSIS AND MANAGEMENT
→ An X-linked recessive or sex-linked autosomal dominant ● History and Physical Examination
---
disorder -
→ Measurement of height, span, and weight
→ Breast absent, Uterus present  serum FSH assay
→ XY karyotype (normally functioning male gonads  normal
I
▪ Hypergonadotropic Hypogonadism (FSH > 30 miu/ml) 
levels of testosterone and DHT) peripheral white blood cell karyotype
0
--O
▪ Lack of receptors in target organs  lack male − (+) Y chromosome  streak gonads should be excised
differentiation of the external and internal genitalia − (-) Y chromosome  signs of hyperandrogenism 
▪ No female or male internal genitalia, normal female remove gonads
external genitalia, and a short or absent vagina.
→ Presents with: ● Elevated FSH level + XX karyotype  electrolyte and serum
r
▪ Pubic hair and axillary hair absent or scanty progesterone levels (r/o 17- Hydroxylase Deficiency)
▪ Normal breast development → 17- Hydroxylase Deficiency  Elevated serum
V
▪ Estrogen levels – normal male range &
progesterone level (>3 ng/ml)
▪ Low 17- Hydroxyprogesterone level (<0.2 ng/ml)
▪a LH – slightly elevated ▪ Elevated serum deoxycorticosterone level (>17 ng/100 ml)
→ Intraabdominal Testes or that occur in the inguinal canal – ▪ Hypertension
increased risk of developing a malignancy (Gonadoblastoma
or dysgerminoma) ● Low FSH  CNS-hypothalamic pituitary disorder  get serum
occur ⑧ prolactin
V
▪ Malignancies - rarely>
before age 20
▪ Gonads left in place after puberty is completed (allow full
- -
→ Prolactin level not elevated  cranial CT scan / MRI to rule
-
- -
breast development and epiphyseal closure) out a lesion

→ Karyotyping  46XX (all hypogonadotropic hypogonadism)
g
▪ Psychologically and phenotypically female and raised as
such  use gonads instead of testes
→ May give Oral Contraceptive pills for breast development and
for epiphyseal closure
- O
→ If fertility is desired, may give pulsatile GnRH or HMG → Weight loss is also associated with amenorrhea in women
and has been classified into two groups:
DIFFERENTIAL DIAGNOSIS ▪ The moderately underweight group, which includes
● MRKH Syndrome - require no hormone
individuals whose weight is 15% to 25% below ideal body
→vRenal scan Al D weight
→ Surgical reconstruction of an absent vagina (McIndoe
v ▪ Severely underweight women, whose weight loss is
procedure, Frank method)
more than 25% of ideal body weight.
malignant potential vOw

● Androgen Resistance – gonads should be removed  ● Polycystic Ovary Syndrome
→ Diagnosis of PCOS may be confirmed by visualizing
④
→ Estrogen therapy
→ Referral to an endocrine center for the extensive evaluation
polycystic ovaries on ultrasound, particularly in the absence
of classic findings such as hyperandrogenism.
A
-
necessary to establish the diagnosis. ● Functional Hypothalamic Amenorrhea
→ Do not exhibit these characteristic cyclic alterations in LH
pulsatility.
B. SECONDARY AMENORRHEA ▪ Either have no pulses or have a persistent pattern of
pulsatility that is normally found in only one portion of the
● ⑧
62% Hypothalamic Disorder
op ovulatory cycle.
● 16% Pituitary Problem
● -Ovarian Problem
12% Primary
&
(POP Pituitary Causes (Hypoestrogenic Amenorrhea)
● 7% Uterine Disorders Cup)
● Neoplasms
→ Chromophobe Adenoma (most common non-prolactin
Uterine Factor A
A No secreting pituitary tumor)
● Intrauterine adhesions (IUAs) or synechiae (Asherman → Basophilic (ACTH-secreting) and acidophilic (GH-secreting)
syndrome)
adenomas may not secrete prolactin.
→ Can obliterate the endometrial cavity and produce secondary
amenorrhea. -> > ▪ Have other symptoms produced by this lesions and
→ Antecedent factor: present to the clinician with symptoms of acromegaly or
▪ Endometrial curettage or Dilation & Curettage (D&C) for: cushing’s disease
−gEvacuation of alive/dead fetus
− PP or post abortal curettage ● Nonneoplastic Lesions
"
− Missed abortion
− Diagnostic curettage
→ Pituitary cells become damaged or necrotic as a results of
-
O
→ A less common cause of IUA is severe endometritis or
anoxia, thrombosis hemorrhage
→ 2 Conditions causing this:
fibrosis following a myomectomy, metroplasty, or cesarean
delivery ▪ Sheehan’s Syndrome
→ Diagnosis: Hysterography, Hysteroscopy − Due to a hypotensive episode during surgery
▪ Simmonds disease
Central Nervous System and Hypothalamic Causes − When unrelated to pregnancy
● Central Nervous System Structural Abnormalities → Decreased ACTH, TSH, LH, FSH
→ The same anatomic lesions in the brain stem or
hypothalamus, which have been discussed as causing Ovarian Causes (Hypergonadotropic Hypogonadism)
Aprimary amenorrhea (by interfering with GnRH release), can ● Follicles are damaged due to infection, interference of blood
also cause secondary amenorrhea.& supply, depletion of follicles  ovaries FAIL to secrete sufficient
→ Which includes: Craniopharyngioma, granulomatous disease estrogen
(TB, Sarcoidosis), encephalitis ● Premature Ovarian Failure / Premature Ovarian Insufficiency 
@
● Drugs occurs before 40
→ Phenothizine derivative,
N antihypertensives,- OC’s “post
W pill → Risk Factors:
amenorrha” ▪ Irradiation, systematic chemotherapy, steroid hormonal
→ Oral
-
contraceptive steroidsO inhibit ovulation by acting on the enzyme deficiency, autoimmune disease
-
hypothalamus to suppress GnRH and directly on the pituitary (Hypoparathyroidism, Hashimoto’s thyroiditis, Addison’s
to suppress FSH and LH. disease)
▪ This hypothalamic-pituitary suppression persists for
several months after oral contraceptives are discontinued,
producing the syndrome termed postpill amenorrhea
DIAGNOSTIC EVALIATION AND MANAGEMENT
● Detailed history and PE
-
● Stress and Exercise
→ Rule out pregnancy – request for PT, serum beta HCG
→ Stressful situations, including a sudden change in
→ Rule out intrauterine adhesions
o
environment (e.g., going away to school), deathA in the family,
▪ Uterine sound, hysterogrpahy / hysteroscopy
or divorce, can produce amenorrhea.
→ Both
-
stress and exercise can increase brain-derived factors ● Check Ovulation – Basal Body Temperature (BBT), Elevated
> -
that can inhibit GnRH release (CRH, opioid peptides etc.) progesterone level
a
● Weight loss ● Medications, Oral Contraceptive Pills
● Diet, weight loss, stress, strenuous exercise
→ Excessive dietary restriction, malnutrition, anorexia nervosa
when we
e
● Signs and Symptoms: Hot flushes, decreased breast size,
vaginal dryness (Sx of estrogen deficiency)
● LABS:
I
→ CBC, Urinalysis
W
→ Serum Chemistries – Rule - out systemic
- disease
→aTSH Assay
→aSerum E2
→-FSH
→aProlactin
→ Progesterone
- Challenge Test – determine whether
sufficient estrogen is present to produce endometrial growth
a
▪ E2 level 30 – 40 pg/ml, (+) progesterone challenge test /
withdrawal bleeding
--
I
- V exercise,r
− PCOS, moderate stress, weightrloss,
hypothalamic-pituitary dysfunction
▪ Very low E2 levels (below)

− Pituitary tumors,v -severe dietary
ovarian failure, -weight
loss, anorexia nervosa, severe stress, hypothalamic
a ~-
lesion\
▪ Low E2, Low FSH

REFERENCES
dHypothalamic-Pituitary failure
− CNS lesion, W  CT scan /
MRI
Dr. Renna de Leon’s PPT and Lecture
Lobo et. al. Comprehensive Gynecology 7Th ed., Part V Chapter 38
▪ Low E2, Elevated FSH (>30 mlU/ml) Page 829 - 851
− Premature Ovarian Failure (POF)
***If no cause of ovarian destruction is elicited in a
young woman  autoimmune disease = test for anti-
N
thyroid antibodies and antinuclear antibodies
N
***Women with POF 25 years old or younger
 Do karyotyping
 Biopsy of the Gonads?? Not necessary
● TREATMENT:
→ Appropriate treatment depends on the diagnosis and on
whether conception is desired
→ Non-prolactin secreting pituitary tumors

▪ Excision of tumor
q ▪ Advise to gain weight

▪ Estrogen supplementation to prevent osteoporosis
→ PCOS: N
▪ monthly progestin administration Medroxyprogesterone
acetate (MPA) 10 mg/day, 1st 12 days of the cycle
▪ If conception is desired, Clomiphene citrate for induction
of ovulation
→ Hypothalamic-Pituitary Dysfunction
▪ Estrogen-progestogen replacement
▪ If conception is desired, exogenous gonadotrophins or
intermittent GnRH
APPENDIX
GYNECOLOGY - FAMILY PLANNING 2020 Source: Comprehensive Gynecology 7th ed (Ch 13) and Marybeth de los Santos, MD's ppt
Family Planning modern methods (mCPR) among

all women
LEARNING OUTCOMES Table 13.3 WHO Summary Table of Contraceptive Efficacy

1. Describe the mechanism of action and effectiveness of
V
a
2.
contraceptive methods
Counsel the patient regarding the benefits, risks, and
use of each contraceptive method including
to
congresnel O
emergency contraception
3. Describe the barriers to effective contraceptive use
a and to reduce unintended pregnancy
4. Describe the methods of male and female surgical
V sterilization and its risks and benefits
I
CONTRACEPTION OVERVIEW
 Passage of the RPRH Law in 2012 - landmark legislation
V in the country's law making history
O
It has laid down the legislative foundation in achieving
a 0
-
I
O
I
reproductive health and rights of all Filipinos towards
v better health outcomes and socioeconomic growth
The Philippine government commits to- providing family
planning services to poor families with zero co-payment  All contraceptive methods have a typical use
-
and to upgrading public health facilities and increasing effectiveness (pregancy rate given actual use,
the number of health service providers including occasional inconsistent or incorrect use) and
perfect use effectiveness (pregnancy rate given
i correct and consistent use of a method with every act
CONTRACEPTIVE USE (PHILIPPINES)
O_onlysington
of intercourse)
Year Total WRA MCPR
Population
2017 104 M 12.9 M 52.8%
formain
2016 103 M 12.7 M 47.8% in
2015 101 M 12.5 M 47.9%
CURRENT CONTRACEPTIVE STATUS

USA
NSTERILIZATION 20.6% courcramme
Pills 16%
Condom 9.4%
LARC 7.2%
Injectable 4.4%
Others 4.1%
LARC - Long acting reversible contraception
 Sterilization - most common contraception used in the

O
USA
TIER 1 METHODS
PHILIPPINES  Highly effective
PILLS 51%  Fewer than 1 pregnancy per 100 women in 1 year
Sterilization 19.3% 22nd only in true puppire)  Intrauterine devices (IUDs), Implants, Male and female
Injection 12.4% -
sterilization
LARC (IUD + Implant) 11.6%  Common to all of them:
Condom 4.4% -  Long acting
LAM 1.2%  They are usually administered by a health
IUD - Intrauterine device; LAM - Lactational amenorrhea method -care provider
 Pills - most common contraception used in the
- - -
LARC (LONG ACTING REVERSIBLE CONTRACEPTION)
Philippines  These methods require only one act of motivation to enable
I
Source: long-term use, which virtually eliminates user error
http://www.familyplanning2020.org/sites/default/files/Data-  They are highly effective and immediately reversible with a
Hub/2019CI/Philippines_2019_CI_Handout.pdf rapid return to fertility after removal
 Do not require frequent visits from resupply or incur costs
=@ma
FAMILY PLANNING INDICATORS after placement (though upfront costs can be high)
2017 2018 2019  When used in the postpartum and postabortion period,
Number of unintended 2.13 M 2.11 M 2.10 M -
LARC and permanent sterilization reduce the risk of short
interval pregnancy significantly when compared to other
pregnancies
Percentage of women with an 35.1% 34.5% 33.9% hormonal methods
O
unmet need for a modern
method of contraception
 According to American Congress of Obstetricians and
Gynecologists (ACOG), LARC methods are
(married/ in-union) recommendedas first-line contraception to most women
Contraceptive prevalence rate, 24.7% 25.1% 25.6%  Examples: Copper T380A IUD, LNG-IUS
Zog
1|I nsi gni s
cexedtectory.
r*)
,M eᵈ"ⁿfe ood
ten
INTRAUTERINE DEVICES (IUDs) o @
60% reduction of MBL during the use of
LNG-IUS
 The most commonly used reversible method of
 Seen as early as 3 months after
Wfaa
contraception worldwide -
 Types of IUD: insertion and persists for the
an
=
1. COPPER T 380A IUD duration of use of the device
E-
 Copper-bearing IUD  After 24 months of use, 50% of
 10 years users have amenorrhea and
 Maintains its effectiveness for at least 12 25% have oligomenorrhea
years  Useful in the prevention and the
 Due to constant dissolution of copper treatment of iron deficiency
(which on daily basis amounts to less than anemia
that ingested in the normal diet), the o Excessive bleeding in the first few months
copper IUDs require periodic following IUD insertion should be treated
replacement with reassurance and supplemental oral
÷
2. LNG-IUS (MIRENA) iron
 The bleeding usually diminishes
 Levonorgestrel- Releasing Intrauterine
with time, as the uterus adjusts
System
to the presence of the foreign
 About 20 ug of levonorgestrel (LNG) is
why
body
released to the endometrial cavity each
: day  PERFORATION
*  It has a high level of effectiveness for at o Rare, potentially serious complications
least 5 years associated with IUD
 It reduces MBL and has been used o Specific site: Uterus (fundus)
therapeutically to treat excessive uterine o Always begin at the time of insertion
bleeding o IUDs correctly inserted entirely within the
 Mechanisms of Action endometrial cavity do not migrate or
 Induce a local inflammatory reaction of the wander through the uterine muscle into
endometrium, creating an environment that is the peritoneal cavity
•
hostile to the sperm so that fertilization of the ovum o Best prevented by straightening the
oowY
does not occur uterine axis with a tenaculum and then
•
Cosi:
 Copper markedly increases the extent of the measuring the cavity with a uterine sound
inflammatory reaction
- before IUD insertion
o Clinician should always suspect a
* o
•
It impedes sperm transport and viability in
perforation if the user cannot feel the
the cervical mucus
•
of
 LNG-IUS thickens the cervical mucus, decreases threads and did not observe that the
_ device was expelled
tubal motility and also produces a thin, inactive
endometrium o Sometimes the IUD is still in its correct
u%"%añ¥⑦ñ
 Insertion position in the uterine cavity, but the
¥
threads have been withdrawn into the
€
 Timing
 The IUD can be safely inserted cavity as the position of the IUD has
&•:•ñ•m
o On any day of the cycle provided the changed
✓ woman is not pregnant  To assess: After pelvic
Immediately postabortion examination has been
]
o
o Immediately postpartum following either performed and pregnancy
vaginal or cesarian section delivery excluded, a transvaginal
o The copper IUD can be used as ultrasound may be performed
emergency contraception for up to 5 to locate the device
days following unprotected intercourse  If the device is not visualized
 Pain with pelvic ultrasonography, a
 Most insertions are easy and accomplished on the radiograph visualizing the
first attempt abdominal cavity should be
 Cervical preparation with misoprostol does not performed to visualize the entire
increase the success of insertion and increases pelvis and abdomen
pain  IUDs found to be outside the
 Ibuprofen administered prior to insertion does not uterus usually can be removed
reduce insertion pain but may be helpful for the by means of laparoscopy
cramping that occurs in the hours immediately  COMPLICATIONS RELATED TO PREGNANCY
following insertion o A pelvic ultrasound must be carried out
 Topical anesthesia does not affect pain, although ←o
to locate the pregnancy
In the event of an intrauterine
a paracervical block may decrease it
 If a narrow cervix prevents the passage of a
uterine sound, a paracervical block should be
placed and dilation performed
¥
pregnancy, the device should be
removed regardless of whether the
pregnancy is desired or undesired
 Difficult insertions should be referred to clinicians o •
If a pregnancy occurs and the IUD is not
with expertise in family planning procedures subsequently removed, the incidence of
 Adverse Effects spontaneous abortion is approximately
 UTERINE BLEEDING three times greater than would occur in
o Copper T 380A IUD is associated with as pregnancies without an intrauterine
loss (MBL)
•
much as 50% increase in menstrual blood
o
device
In the case of an undesired pregnancy, a
manual vacuum aspiration can be
2|I nsi gni s
performed with the IUD in place for contains 68 mg of etonogestrel (ENG)
removal of both the pregnancy and the  Main mechanism of action: Ovulation inhibition
device  Thickening of the cervical mucus also occurs
 INFECTION IN THE NONPREGNANT IUD USER  Ovulation is completely inhibited for at least 30 months after
o The placement process, not the device insertion
¥
itself or its thread, creates a transient risk  Resumes rapidly, and 90% of women ovulate within
of infection 1 month after removal
 Most common reason for discontinuation: Bleeding
/
Clinical suspicion of infectious
o
>
¥
endocervitis, or if the patient has 2 out of irregularities
3 of the following: (a) purulent vaginal  Women experience changes in their regular
discharge, (b) adnexal tenderness, or (3) ✓bleeding pattern
0
before
cervical motion tenderness, testing for  Amenorrhea is common, occurring in about 20% of
of gonorrhea and chlamydia should be

Ymo
women, and 27% have infrequent bleeding
roof
mm
performed and themmIUD insertion delayed  About 12% of women have prolonged bleeding,
o Positive gonorrhea or chlamydia and 6% have frequent bleeding
screening tests that occur with an IUD  Other implants:
µ
already in place (i.e., more than 3 weeks  Jadelle - 2-rod system containing 75 mg
after insertion) can usually be successfully levonorgestrel approved for up to 5 years of use
treated without removing the IUD  Sino-implant - 2-rod system containing 75 mg
o For a symptomatic patient continuing an levonorgestrel
:Ffsmof
IUD, an antibiotics regiment for PID  Norplant - 6-rod system containing 216 mg
⑨ me
approved by the Centers for Disease levonorgestrel approved for 7 years of use
Control and Prevention (CDC) should be PERMANENT CONTRACEPTION: STERILIZATION
used until the woman becomes symptom  Considered permanent
free  If women who have tubal sterilization wish to conceive,
÷:O
"o If the infection does not improve or if in vitro fertilization is now being performed more frequently
there is evidence of tubo-ovarian than tubal reconstructive surgery
• abscess, the device should be removed  MALE STERILIZATION
after a therapeutic serum level of  Aka. Vasectomy
appropriate parenteral antibiotics has  A safe and highly effective outpatient procedure
been reached, preferably after a clinical that takes about 20 minutes and requires only
response has been observed local anesthesia
o Actinomyces organisms are often  It does not involve entry into the peritoneal cavity
identified in routine cytology in women  About 13-20 ejaculations (3 months) must occur
with IUDs in place after the operation before the ejaculate will be
 Contraindications sterile
Er
1. Pregnancy or suspicion of pregnancy o Absence of sperm is confirmed with a
2. Acute pelvic inflammatory disease (PID) semen sample
3. Post-partum endometritis or infected abortion  FEMALE STERILIZATION
4. Known or suspected uterine or cervical
¥
 Sterilization for women blocks fertilization by
malignancy cutting or occluding the fallopian tubes and
5. Genital bleeding of unknown origin, and preventing the union of the sperm and egg
6. A previously inserted IUD that has not been  This is the most prevalent method of contraception
removed used by U.S. women over the age of 30
 Overall Safety
 TRANSABDOMINAL APPROACH
 It is not associated with an increased incidence of
o Tubal occlusion can occur at the time of
endometrial or cervical carcinoma; rather, it is
cesarean section, immediately
associated with a reduction in risk of developing
postpartum through an infraumbilical
these neoplasms
minilaparotomy while the uterus is still
 Particularly useful method of contraception for
enlarged or during an interval
women who have completed their families and
milaparotomy
have contraindications to sterilization
o Ligation and resection of a portion of
 Lippes Loop IUD - a phased out IUD; it is loop shaped and
both fallopian tubes using a technique
placed in the endometrium; it has no copper and LNG
such as the modified Pomeroy method is
 Improper placed IUD - most common cause of pregnancy
common
in IUD users
j¥¥q
o This is the most common approach done
SUBDERMAL IMPLANTS in the Philippines

0
Effectiveness equal or superior to that of sterilization and
IUDs
 LAPAROSCOPIC APPROACH
o General anesthesia is used
 Consists of one or more thin rods containing a progestin o This method was abandoned due to an
hormone increased risk of surgical complications
 Insertion is performed in the outpatient setting, and the o The most common techniques used
entire procedure takes less than 5 minutes today include bipolar cautery, the Filshie
 After skin infiltration with local anesthesia, the clip, and Silastic band (Falope ring)
implant is inserted superficially into the
 TRANSCERVICAL APPROACH
subcutaneous tissue of the upper arm using a
o Sterilization using the Essure device
trocar
involves the introduction of a microinsert
 The insertion site is closed with adhesive, without
device transcervically through a
the need for suture
hysteroscope
 Nexoplanon - most commonly used implant in the US;
 The device is placed in the
3|I nsi gni s

proximal portion of the fallopian of women resume a regular cyclic
tube menstrual pattern within 6 months and
 Over time, the device causes about three fourths have regular menses
tissue ingrowth and permanent within 1 year
tubal occlusion  WEIGHT CHANGES
o A hysterosalpingogram is performed 3 o 1/4 of women gain weight (usually in the
months after insertion to document tubal first 6 months of use)
occlusion o Should be used with caution in patients
who are overweight and obese
 MOOD CHANGES
TIER 2 METHODS o Incidence of depression and mood
 Effective change in women using this method of
 6-12 pregnancies per 100 women in 1 year contraception is less than 5%
 Injectables, pills, patch, ring  HEADACHE
o Most frequent medical event reported by
INJECTABLE SUSPENSIONS DMPA users
 Depo-medroxyprogesterone acetate (DMPA)

0
Given in a dose of 150 mg intramuscularly (IM) or
o Common reason for discontinuation of
use
⑧
104 mg subcutaneously (SC) every 3 months
An extremely effective contraceptive
 BONE LOSS
o Because DMPA suppresses production of
=
 It is a long-acting injectable formulation of estradiol, bone remodeling is increased
medroxyprogesterone acetate (MPA) and may resemble menopause
 Consists of a crystalline suspension of MPA o Longer-term studies indicate that bone
 Involves 3 mechanisms of action: loss is reversible after stopping DMPA use
1. Inhibition of ovulation by suppressing o Measurement of bone mineral density
4%
levels of FSH and LH and eliminating the
LH surge
dittany e during DMPA use is unnecessary because
bone density increases after stopping
2. Thickening of cervical mucus inhibiting DMPA and bisphosphonate therapy
sperm from reaching the oviduct should not be used in DMPA users with
3. Altering the endometrium (cause low BMD
atrophy)  Non-contraceptive health benefits
 Return of Fertility  It reduces the risk of developing iron deficiency
 Resumption of ovulation is delayed on average of anemia and PID
6 months and as long as 1 year after a single  Reduced risk of endometrial cancer
injection  Reduces the incidence of primary dysmenorrhea,
 The median delay to conception is 9 to 10 months symptoms of endometriosis, ovulation pain, and
after the last injection, with a wide range in functional ovarian cysts because it inhibits
resumption of ovulation, from 15 to 49 weeks from ovulation
the last injection  Clinical Recommendations
 Women who wish to become pregnant after  DMPA can be started at any time during the
discontinuing DMPA should know that they might menstrual cycle as long as the woman and her
experience a delay in the resumption of fertility provider are reasonably certain that she is not
until the drug has cleared from their circulation pregnant
¥
o After this initial delay, fecundity is similar  If given later than 7 days into the menstrual cycle,
to that found after discontinuing a barrier backup contraception should be used for 7 days
contraceptive  Women should be informed prior to receiving the
 Clinical Side Effects first injection of the occurrence of irregular
 BLEEDING PATTERNS bleeding and the development of amenorrhea
o Change of menstrual cycle - major side  Women need to know that the action may last as
o reffect of DMPA
In the first 3 months after the first injection,
long as 1 year following the last injection if they
decide to discontinue use of DMPA
about 30% of women experience  It is not part of the tier 1 methods though it is administered
amenorrhea; 30% to 40% have irregular by a healthcare provider since it is not a one-time
bleeding and spotting occurring more procedure; it needs to be re-administered
than 11 days per month ORAL CONTRACEPTIVES
o It does not cause anemia (its only light
bleeding) ↳ 

Most widely used method of reversible contraception
• •
Combination of EE with one of several synthetic progestins
o As the duration of therapy increases, the  Major effect of the progestin component: Inhibit ovulation
incidence of frequent bleeding steadily
declines and the incidence of

←
Progestin also contribute other contraceptive
actions such as thickening of the cervical mucus
amenorrhea increases and thinning of the endometrium
o At the end of 1 year, about 55% of  Major effects of the estrogen:
o
women experience amenorrhea
After 2 years, about 70% of women
① Maintain the endometrium (prevent unscheduled
bleeding)
experience amenorrhea  Inhibit follicular development through a synergistic
o Women who use this method should
receive counseling that with time
⑨ effect with the progestin
 3 major types of oral contraceptive formulations include:
irregular bleeding will diminish and 1. Progestin-only pills (POPs) or minipills
amenorrhea will most likely occur 2. Fixed-dose (monophasic) combination pills - most
o After discontinuation of DMPA, about half commonly used
4|I nsi gni s

3. Multiphasic combination pills relative contraindication to use of a
 Regimens are packaged in a 28-day (4 week) cycle combined hormonal method
 Many combination OC formulations provide active pills o Use of OCs by women older than age 35
continuously for 21 days (3 weeks) followed by a 7-day who also smoke is contraindicated due
hormone free interval (HFI) to the risk of myocardial infarction
 Most common pill packs in the Philippines:  Return to fertility
-=-p::::r
1. 28-day pill pack - contains 28 pills; it has a different o After discontinuation of low-dose OCs,
•
color for the 1st 21 days (active pills) and a the suppressive effect on the
different color for the remaining 7 days (placebo hypothalamic-pituitary-ovarian axis
pills; contain iron) disappears quickly
o Benefit: When a woman starts to take a o After the initial recovery, completely
pill, normal endocrine function occurs
2. 21-day pill pack o There is little, if any, effect of duration of
o Disadvantage: Women may forget to OC use on the length of delay of
count the 7-day hormone free interval subsequent conception
 1st vs 4th generation progestin: 4th generation progestin o There is no risk of congenital
have lesser side effects and more effective malformations or other adverse
 Mechanism of action outcomes in pregnancies among women
 Combination oral contraceptives suppress who conceive while taking OCs or shortly
gonadotropins thereafter
 The estrogen component prevents a rise in follicle-  Neoplastic Risks and Benefits
stimulating hormone (FSH) and enhances the o BREAST CANCER
effect of the progestin component, which inhibits  OC use increases the risk of
ovulation and, specifically, the luteinizing hormone breast cancer by 25%
(LH) surge  High risk of developing breast,
 These dual actions lead to inhibition of follicle
! including women with an
Digest;
development and ovulation. The lowest amount of immediate family history of
a progestin needed to suppress LH is the ovulation breast cancer and those with
inhibition dose BRCA-1 and BRCA-2 mutations
 Changes in the cervical mucus (which prevent o CERVICAL CANCER
sperm transport into the uterus), the fallopian tube o LIVER ADENOMA, AND CANCER
(which interfere with gamete transport), and the  Rare
endometrium (which reduce the likelihood of
implantation) represent secondary contraceptive
-
 An increased risk of this tumor
was reported in early OC studies
I ;÷÷÷÷t
effects of the progestin component of prolonged use of high-dose

 ¥
Estrogen induces endometrial proliferation
Progestins oppose the mitotic action of estrogen,
leading to a stable decidualized endometrium
formulations
 Women with active liver disease
should not use hormonal
 Metabolic effects contraception, as the liver is a
 More common adverse effect: major site for the metabolism of
o Nausea (12%) synthetic steroids
o Breast tenderness (9%) o ENDOMETRIAL CANCER, OVARIAN
o Headache (18%) CANCER, COLORECTAL CANCER
◦
•
 OCs decrease androgen levels, which tends to reduce  Noncontraceptive Health Benefits
acne o Some of the immediate benefits of OC
 oWeight gain represents a common complaint of women
using hormonal contraception
use include improvement of menorrhagia
and dysmenorrhea and decreased acne
 PROGESTIN-ONLY PILLS (POPs) o As a result of the antiestrogenic action of
 The minipill formulations consist of tablets the progestins in OCs, there is less
containing a low dose of progestin and no proliferation of the endometrial glands
estrogen  This reduces the amount of
 Taken at the same time of day to ensure that blood loss at the time of
blood levels do not fall below the effective endometrial shedding
contraceptive level  Less likely to develop iron
 With minipill use, many women may still ovulate; deficiency anemia
therefore, estradiol and progesterone produced o Significantly less likely to have
by the ovary will affect endometrial bleeding menorrhagia, irregular menstruation, or
patterns intermenstrual bleeding
 Women may experience irregular bleeding, o As OCs inhibit ovulation, they can reduce

-
individual woman’s response

Coagulation parameters
→
spotting, or amenorrhea, depending on an
-
such
dysmenorrhea
syndrome
ovulatory
and
disorders
premenstrual
as
o Combined oral contraceptives (COCs)  Contraindications to Oral Contraceptive Use
:
increase the risk of venous o Absolute contraindications, including a
thromboembolism (VTE) history of vascular disease
o The increased risk is related to the (thromboembolism, thrombophlebitis,
estrogen component of the pill and is atherosclerosis, and stroke) and systemic
dose dependent diseases that may affect the vascular
o Obesity is a modest risk factor for VTE, system (active lupus erythematosus with
and extreme obesity (e.g., a body mass vascular involvement or diabetes with
index [BMI] >40) should be considered a retinopathy or nephropathy)
5|I nsi gni s
Cigarette smoking by OC users older should be initiated no sooner than 6
BA : 160/ too
o
{o
than age 35 and uncontrolled -
hypertension are also contraindications
As breast or endometrial cancer may
weeks after delivery as the increased risk
of postpartum thromboembolism may be
further enhanced by the
involve hormone-sensitive tumors, hypercoagulable effects of combination
avoiding OC use is prudent OCs
o Other contraindications include o Progestin-only methods can be initiated
undiagnosed uterine bleeding and immediately
elevated triglyceride levels o Estrogen inhibits the action of prolactin in
o Pregnancy is an obvious contraindication breast tissue receptors; therefore, the use
 OCs are not teratogenic nor will of combination OCs (those containing
they negatively affect both estrogen and progestin) diminishes
pregnancies occurring during or the amount of milk produced by OC
after use users who breast-feed their babies
o Women with active liver disease should o The major concern is that combined OCs
not take OCs will lower the success of initiation of
o Women who have recovered from liver lactation
disease, such as viral hepatitis, and o Women at high risk of unintended
whose liver function tests have returned pregnancy following delivery should
to normal can safely take OCs consider the relative advantages of a
o Relative contraindications to OC use combination pill over other methods
include heavy cigarette smoking o Progestins do not diminish the amount of
% ]
younger than age 35, migraine breast milk, and progestin-only OCs are
¢
headaches, and undiagnosed causes of
amenorrhea or genital bleeding
highly effective in this group of women,
though not recommended by some prior
o Women who have migraine headache to 6 weeks postpartum with breast-
with aura or peripheral neurologic feeding
symptoms should not use oral  CYCLING WOMEN
contraceptives oSunday starts have been a popular
o Women with migraine headaches recommendation; however, delaying the
without aura under 35 years of age can start of a pill pack can lead to
use OCs unintended pregnancies
o OC use may mask the symptoms o Starting a pill pack on the same day as a
qgY¥m
produced by a prolactin secreting clinic visit instead of waiting until after
adenoma menses allows for a quicker onset of
wok
 Women with either contraception with no adverse effects on
galactorrhea or amenorrhea bleeding patterns and is highly
should not receive OCs until a acceptable to many women
diagnosis is established  Type of Formulation
 If galactorrhea develops during  Doses with 35 μg or more of estrogen are rarely
OC use, OCs should be used because of the cardiovascular risks and
discontinued, and after 2 weeks estrogenic side effects
a serum prolactin level should  Progestin-only contraceptive formulations have a
be measured. If elevated, lower incidence of risks than do the combination
further diagnostic evaluations formulations
are indicated  Because the factors that predispose to
o Women with diabetes without thromboembolism are caused by the estrogen
cardiovascular progression can take low- component, the incidence of thromboembolism in
dose OC formulations, because these women taking the minipill is not increased
agents do not affect glucose tolerance compared to nonusers
or accelerate diabetes mellitus CONTRACEPTIVE PATCH
 Beginning Oral Contraceptives
 The contraceptive skin patch Ortho Evra, contains 75ug
 ADOLESCENTS ethinyl estradiol and 6 mg norelgestromin
o A pubertal girl who has demonstrated  One patch is applied to the skin each week for 3
maturity of the hypothalamic-pituitary- consecutive weeks and no patch for the following week of
ovarian axis with presumably ovulatory a 4-week cycle to allow withdrawal bleeding
menstrual cycles can begin OCs without  May be applied to one of four anatomic sites: buttocks,
concern that their use will alter future upper outer arm, lower abdomen, or upper torso excluding
reproductive endocrinologic function the breasts
o It is also not necessary to be concerned  Following skin application, both steroids appear in the
about accelerating epiphyseal closure in circulation rapidly and reach a plateau within 48 hours
the postmenarchal female  Mechanism of action: Inhibition of gonadotropin release
 Endogenous estrogens have and prevention of ovulation
already initiated the process a
CONTRACEPTIVE VAGINAL RING
few years before menarche,
 A flexible ring-shaped device containing 2.7 mg of ethinyl
and use of contraceptive
estradiol and 11.7 mg of etonogestrel
steroids will not hasten this
 The contraceptive ring (NuvaRing) is placed in the vagina
process
for 21 days and then removed for up to 7 days to allow
 AFTER PREGNANCY
withdrawal bleeding
o For women who deliver after 28 weeks
 Mechanism of action: Inhibition of gonadotropin release
and are not nursing, the combination pills
6|I nsi gni s
and prevention of ovulation does not require fitting by a health
 Because each ring delivers sufficient steroids to inhibit professional, like the male condoms
ovulation for 6 weeks, contraceptive action can be  The typical use failure rate at 1 year is estimated to
assumed even if the ring is left in place beyond 21 days be 21%
 Contraceptive effectiveness as well as metabolic and LACTATIONAL AMENORRHEA METHOD (LAM)
clinical effects are similar to that for combination oral  Criteria for successful use are continuous amenorrhea and
contraceptives exclusive breast-feeding (no supplements) for up to 6
months after delivery
When used correctly, the failure rate in the first 6 months
;YᵗHDRAw-_

TIER 3 METHODS postpartum is less than 2%
 Effective  Effective use of LAM improves with education regarding the
 18 or more pregnancies per 100 women in 1 year efficacy of the method
 Barrier methods, Lactational amenorrhea, Periodic
abstinence, Coitus-related methods
PERIODIC ABSTINENCE ( Natural family Planum method
 Many motivated couples use abstinence from sexual
intercourse or a barrier method during the days of the
BARRIER METHODS menstrual cycle when the ovum can be fertilized
 DIAPHRAGM AND CERVICAL CAP  CALENDAR RHYTHM METHOD
 Creating a mechanical barrier between the  Oldest

vagina and cervix
DIAPHRAGM
o Thin, dome-shaped membrane of latex

¥
Period of abstinence is determined by calculating
the length of the individual woman’s previous
menstrual cycle and makes 3 assumptions:
rubber or silicone with a flexible spring 1) Human ovum can be fertilized for only
modeled into the rim about 24 hours after ovulation
o The spring allows the device to be 2) Sperm can fertilize for 3 to 5 days after
collapsed for insertion and then allows for coitus
expansion within the vagina to seat the 3) Ovulation usually occurs 12 to 16 days
rim against the vaginal wall, creating a before the onset of menses
 The woman establishes her fertile period by
*ñ
mechanical barrier between the vagina
and the cervix subtracting 18 days from the length of her previous
o Caya shortest cycle and 11 days from her previous
 CERVICAL CAP longest cycle and abstains from coitus during this
o Cup-shaped silicone or rubber device time
that fits around the cervix  Other periodic abstinence methods rely on CYCLIC
o FemCap - soft, durable, hypoallergenic, PHYSIOLOGIC CHANGES
silicone rubber, is designed to contact  Increasing levels of progesterone occurring after
the vaginal walls as the dome of the ovulation cause a detectable rise in daily basal
device sits over the cervix body temperature
 The diaphragm and cervical cap should be used  The woman must abstain from intercourse from the
mmmm
with a spermicide and be left in place for at least 8 cessation of menses until the third consecutive day
:
hours after the last coital act of elevated basal temperature, or when she is
 MALE AND FEMALE CONDOM postovulatory
 Prevent both pregnancy and the transmission of  CERVICAL MUCUS METHOD
sexually transmitted infections (STIs)  Woman recognizes and interprets the presence
 The condom should be applied to the erect penis and consistency of cervical mucus
before any contract with the vagina or vulva  Increasing estradiol levels increase the production
o The tip should extend beyond the end of of cervical mucus
the penis by about half an inch to collect  The calendar, temperature, and cervical mucus methods
the ejaculate can be used separately or in combination with one another,
o After ejaculation, the penis must be or the symptothermal method
removed from the vagina while still  Overall typical failure rates are around 24%
somewhat erect, and the base of the  Women with irregular cycles should not use periodic
condom grasped to ensure the condom abstinence methods, over the age of 35, or immediately
is removed without spillage of the following a pregnancy
ejaculate COITUS-RELATED METHODS
 Water-based lubrication may reduce condom  SPERMICIDES
breakage  Consist of an active agent and a carrier
 Female condom - consists of a soft, loose-fitting
o Carriers include gels, foams, creams,
polyurethane sheath with two flexible rings tablets, films, and suppositories
o One ring lies at the closed end of the o Active agent is a surfactant that
sheath and serves as an insertion immobilizes or kills sperm on contact by
mechanism and internal anchor for the destroying the sperm cell membrane
condom inside the vagina  Must be placed into the vagina before each coital
o The outer ring forms the external edge of act, often in combination with a barrier
the device and remains outside the contraceptive to increase effectiveness
vagina after insertion, thus providing  The contraceptive sponge, a cylindric piece of soft
protection to the introitus and the base of polyurethane impregnated with 1 mg of
the penis during intercourse nonoxynol-9 spermicide, must be inserted into the
o Prelubricated and intended for one-time vagina before intercourse and is effective for 24
use only hours
o Device is available over the counter and
7|I nsi gni s

 Failure rate: 15-25%  Confirms that the woman understands
 COITUS INTERRUPTUS (WITHDRAWAL) instruction
 Removal of the penis from the vagina prior to  RETURN
ejaculation to prevent pregnancy  Plan for next steps and for when she will arrive
%
 Ancient male-controlled method of contraception to hospital for delivery
without contraindications, devices, or cost  Plans for next step
 It can fail because of the small numbers of sperm
present in some preejaculate, the fluid produced NOTES TO REMEMBER:
by the penis during sexual excitement and before Responsible Parenthood and Reproductive Health Act of 2012
climax  For 18 years and below = parent's consent is needed to
 A major drawback of the method is the lack of avail any of the family planning method
any protection against sexually transmitted  If the woman chooses a permanent family planning
infections method = spousal consent is important; if spouse is not
 Failure rates range from 4% with perfect use to 22% around, a witness (a relative may do) should be
with typical use present
EMERGENCY CONTRACEPTION (EC)  Counseling is very important
 Prevent pregnancy after an act of unprotected intercoure
 Morning after pill, EC can actually be used up to 120 hours
after intercourse, depending on the method ] used for soaps
 YUPZE METHOD
Tatem:{Tighter
 Involves 1 dose of one to six oral contraceptive .
* =
(OC) tablets, depending on-
dose 12 hours after
the brand,=
with a 2nd
 Currently, most dedicated EC medications contain the

progestin levonorgestrel
 The copper IUD is the most effective form of EC
COUNSELING GUIDE
GATHER TECHNIQUE
 GREET
¥¥
 Establish a good rapport and indicate
I
counseling on family planning
 Establish a supportive, trusting relationship
 Allows a woman to ask
 Engages woman's family members
 ASK
 Determine reproductive intentions,
knowledge of pregnancy risk and use of
various contraceptives
 Determines any previous experiences with
family planning

0
Assesses partner or family attitudes about
family planning
 Assess reproductive intentions
 Assesses need for protection against sexually
transmitted infections
 Determines interest in a particular family
method
 TELL
 Provide the woman with information about
±
postpartum family planning (PPFP)
 Provides general information about benefits of
healthy spacing/ limiting
 Provides information about postpartum family
planning (PPFP) methods
 HELP
 Assist the woman in making a choice; give her
additional information that she might need to
make a decision
 Helps the woman to choose a method
%
 Supports the woman's choice
 EVALUATE AND EXPLAIN
 Determine whether she can safely use the
method; provide key information about how
to use the method
 Discusses the advantages of the postpartum
intrauterine device (PPIUD)
 Discuss limitations and warning signs
8|I nsi gni s

Gynecology: Reproductive Endocrinology 08142020
Dr. Renna Christina de Leon • The foremost modulatory influence on the frequency
PPT Audio Comprehensive Gynecology 7th ed and amplitude of GnRH pulses is exerted by the ovarian
steroid hormones through their feedback loop actions.
HPO Axis
- Metabolic influences and GnRH release
Functional Reproductive System

·
⑧
• Accurate integration of energy balance
• Imbalance – reproductive dysfunction and
amenorrhea
o Nutritional deprivation – are known to interfere
O O
o Br
with the normal reproductive process.
Abn eating habits
• Anorexia nervosa
V N • Obesity
• Growing evidence indicates that complex and

⑧ brain extensively integrated physiologic mechanisms
connect an active reproductive axis to the metabolic
-spertralam,
pulle• state.
CURA f
The brain, and in particular the hypothalamus and the
great f O
-
* Everything is interconnected. Not one organ functions alone.

v
GnRH pulse generator, function as the center for the
* Reproductive process begins in the brain. integrative metabolic response process.
Hypothalamus and GnRH Leptin

•
I
O
The reproductive process begins in the brain, through
the activation of the initial hormonal signal that will
release gonadotropins from the pituitary gland.
N② •
•
•
Energy related protein (anorexigenic)
produced by adipocytes
Reduced – if – decrease in body fat stores ie fasting
• High levels conducive to reproduction;
• Gonadotropin-Releasing Hormone (GnRH) • O
Administration of leptin stimulates secretion of GnRH
·
o Produced in the hypothalamus, specifically in
the medial basal awn
hypothalamus, with greatest f
and gonadotropins with the effects most pronounced
in individuals showing signs of reproductive impairment
number in the arcuate nucleus
Initial hormone signal that will release
• O
Peripheral injections of leptin can prevent the reduction
o
<
gonadotropins in the pituitary gland 7 in GnRH/gonadotropins and the disturbances in
cyclicity that accompany caloric reduction.
o Decapeptide (10 AAs)
a • The GnRH pulse generator actually acts as the link that
connects the environment, the internal milieu, and the
o GnRH neurons olfactory placode A reproductive axis. Its overall activity most probably
ODo not originate within the brain like reflects the summation of simultaneous stimulatory and
the majority of neurons inhibitory inputs.
Derived from > progenitor cells in the • It is evident that events, disorders, or drug
embryonic olfactory placode.
X administration may tip the physiologic balance, cause
orie I f
o 16 weeks of life – functional connections
between GnRH neurons and the hypophyseal f
disruption or cessation of GnRH pulse activity, and lead
to disruptions of the menstrual cycle and to
>
portal system [transport GnRH to the anterior reproductive disorders such as oligomenorrhea and
pituitary gland] -- hypothalamic amenorrhea.
o Kallman syndrome – migration failure of the
f
GnRH neurons and the resultant Nlack of the Anterior Pituitary Gland 2
establishment of functional connections • AKA adenohypophysis
-Hypogonadotropic hypogonadism o Derived from the Rathke pouch
of
Anosmia -• Gonadotropes – produce gonadtropins A
o GnRH released intermittently in a pulsatile
fashion -• Prolactin – inhibit GnRH release [inhibit kisspeptin-1]
o Anovulation and hyperestrogenic
o It occurs ata hourly intervals and -v
amenorrhea
communication is through gap junctions
o Induces egg maturation, rv ovulation and
a
initiation of puberty
and
Activation of the GnRH Receptor
orana
Hormones
Modulatory influences on GnRH Pulsatility
A
1.GnRH activation of the receptor
d
Ovarian * estradiol – decrease GnRH pulse amplitude
e
steroid
hormones
E* progesterone – decrease GnRH pulse
frequency
Stimulatory * neuroepinephrine (NE) 2. GnRH receptor stimulates
inputs * neuropeptide Y (NP Y)
* biogenic amine dopamine (DA)
~ cellular production of DAGs
Inhibitory * Gamma amino-butyric acid (GABA)

3. Activate cellular proteins
->
inputs * Dopamine (DA) 4. Increased
* β endorphin intracellular calcium
* Corticotropin-releasing hormone (CRH) ↓

neurons
5. Release of
LH and FSH
• Homologous desensitization or downregulation of the Gonadotropins
receptor – reduced response of GnRH-R in the
gonadotropes to constant GnRH concentrations T Follicle-Stimulating Hormone Luteinizing Hormone (LH)
o Reduction in the ability of GnRH to elicit - (FSH) -
gonadotropin release after prior exposure to
GnRH I Acts on the granulosa cells
- -
- -
Acts on the theca cells and
luteal
-
cells
-
Stimulate follicular growth Stimulate ovarianO

steroid
• a
Pulses of GnRH released by the GnRH neurons in the
-
- -
1C hormone production
arcuate nucleus reach the gonadotropes in the
• N
These GnRH pulses then act on GnRH receptors (GnRH- A
anterior pituitary via the hypophyseal portal circulation. •
•
Similar α subunit (Same with hCG and TSH)
Different β-subunits
R) on the gonadotropes to stimulate both the synthesis
and release of both gonadotropins, LH and FSH
• Females with GnRH-R mutations typically present with • A third gonadotropin, chorionic gonadotropin [hCG],
incomplete or absent pubertal development and is produced in the primate by the placenta.
primary amenorrhea.
Oogenesis (Ovarian Gametogenesis)
GnRH Analogues and the GnRH Receptor - Begins in fetal life
• The GnRH half-life in the peripheral circulation is very
short as peptidases rapidly degrade naturally occurring
GnRH by cleaving the decapeptide molecule at the
Gly6 to Leu7 and at the Pro9 to Gly10 bonds.
• However, by substituting amino acid 6 in the natural
GnRH molecule with a d-amino or replacing amino
acid 10 with a N-ethylamide (Na-CH2-CH3) or Aza-Gly
(NHNHCO) moiety, gonadotropin-releasing hormone
analogues (GnRH analogues) were synthesized and
shown to have acquired a greater resistance to
enzymatic proteolysis and hence a longer half-life
(hours versus 2 to 4 minutes).
GnRH analogues/agonist
•
I
Greater resistance to enzymatic proteolysis
half-life amm
longer
• Following adm of these agonists Initial stimulation of

r
gonadotropin release (flare) followed by the process
of desensitization
• Induce a “medical castration” state – shuts down the
pituitary-gonadal axis in a variety of clinical conditions Primordial • Migrate to the genital ridge
GnRH antagonists
germ cells
or oogonia
O
• 2nd month of fetal life 600,000
• 6th to 7th month of fetal life – 7 million
• Compete with GnRH for receptor sites
activating a stimulatory signal
V
never
-
Meiotic Division
• O
Rapidly decreasing LH and FSH release
• Thus GnRH antagonists have the advantage
GnRH agonistsv
- - - a
over the
of a rapidly decreasing LH and FSH
Primary
oocytes I • Diplotene stage of prophase (germinal
vesicular stage)
• Remain until stimulation by gonadotropins in
release, without the flare. I adulthood
- -
• At birth 2 to 4 million O
become 90%
N
depleted by puberty
• Age 37 25,000
N
• Age 50 O
1000 oocytes remain
Folliculogenesis
Primordial
pollicle a a
↓
Pumany
pooue
↓
seconda e
d
Antral
Carey
are a
pave
salato
- O
O &
1 f
v
r
* Primary/Preantral Follicle – development is relatively

independent of pituitary control
N &
⑧
-
-
O
N
aron i
* Primary/Preantral Follicle – development is relatively

independent of pituitary control
One primary function of the ovary is the secretion of ovarian

O steroids, which occurs following binding of both FSH and LH
to their respective receptors.
Three primary ovarian hormones

• Estradiol (the primary estrogen)
V
•
•
Progesterone
Androstenedione
v=f **-
• These hormones are the chief secretory products of the
maturing follicle, the corpus luteum, and the ovarian
in
IIsitmental
stroma
Other hormones secreted by the ovary:

• Estrone (a less potent estrogen)
o
I
• Pregnenolone
• 17-hydroxyprogesterone
• Testosterone
• r Dehydroeplandrosterone (DHEA)
* Ovarian hormones are steroid hormones.

* All steroid hormones whether secreted from the ovaries, testes
or adrenals are derived from acetate, which in a series of
reactions is transformed into cholesterol.
Major sites of steroid metabolism:
• Liver
o a
Oxidized by cytochrome P450 oxidase
enzymes from bile acids [final products]
=>
• Kidney
o Conjugation
-
transformed from lipophilic
compounds into metabolites that are readily
water soluble and can be eliminated in urine
Estradiol-17 glucuronide, estrone
sulfate and oregnanediol-3-
glucuronide (the major urinary
metabolite of progesterone)
Prostaglandins
• Subclass of eicosanoids and prostanoids
• Androgens are converted to the estrogens estrone or • Mediators of inflammatory and anaphylactic reactions
estradiol by the enzyme aromatase, through the loss of
the C-19 methyl group and the transformation
men
of the A-
N •
•
Arachidonic acid – most abundant precursor
Their biosynthesis can be inhibited by several groups of
mmm
ring to an aromatic state through oxidation and compounds:
subsequent elimination of a methyl group. o nonsteroidal anti-inflammatory drugs (NSAIDs)
• The aromatic (or phenolic) ring is characteristic of the type 1 (aspirin and indomethacin), which
estrogens f inhibit endoperoxide formation (the
- immediate precursor of eicosanoids), and
• The aromatase enzyme is found in many tissues besides o type 2 (phenylbutazone), whichO inhibits the
the gonads, such as the endometrium, brain, placenta, ~ action of endoperoxidase isomerase and
bone, skin, and others. reductase.
• It is also particularly relevant to note that in humans, in o Corticosteroids also can inhibit prostaglandin
O
contrast to other species, estrogens are also
then
synthesis.
G synthesized in adipose tissue, which in the • Produced intracellularly shortly before they are
released and generally act locally
N
postmenopausal woman becomes the major site of
estrogen biosynthesis. • Ability to modulate the responses of endogenous
stimulators and inhibitors, such as ovarian stimulation by
* AROMATASE DEFICIENCY LH, which is modulated by prostaglandin F2a (PGF2a),
⑧
- Mutation of CYP19
~
which in turn regulates ovarian receptor availability
↓- inherited in an autosomal recessive way
- Accumulation of ANDROGENS during pregnancy - virilization
•
•
Play an important role in ovarian physiology
Help control early follicular growth
at birth > o Increase blood supply to certain follicles
I O
- Individuals of both sexes have abnormal pubertal maturation o Induce FSH receptors in granulosa cells of
and are tall because of the lack of estrogen to affect epiphyseal preovulatory follicles
closure. -a • PGF2a and PGE2 Follicular
- fluid of preovulatory
I- Female patients will have primary amenorrhea follicles
off
-
Assist in follicular rupture
A
- o
* Aromatase Inhibition leads to profound hypoestrogenism. o Concentration increase progressively from the
* Aromatase Inhibitors have become useful in the management proliferative to the secretory phase of the
of patients with estrogen receptor positive tumors eg breast cycle
cancer o Highest levels – menstruation
o Help regulate myometrial contractility
Once in the circulation, ovarian steroids….. o Play a role in regulating the process of
Sex hormone-
binding (SHBG)
a A
• B-globulin synthesized by the liver
• High affinity but low capacity for steroids
menstruation
• Binds dihydrotestosterone, testosterone and Inhibin

estradiol • Family of glycoproteins
-
• Premenopausal women • α-βA (inhibin A) and as α-βB (inhibin B)
o 65% of testosterone is bound to SHBG; • The ovaries are the only source of circulating dimeric
30% to albumin and the 5% is free inhibins.
• a
Preferential inhibition of FSH over LH through their own
V
a
o 60% of estradiol is bound to SHBG, negative feedback loop
38% to albumin, 2% to 3% is free o Decline in FSH after its peak in the early
• Increased by estrogens (oral contraceptives, follicular phase of the normal cycle results
- pregnancy) and by thyroid hormone from a negative feedback action of inhibin B
(hyperthyroidism) at the pituitary level
V
• Circulating patterns of inhibin A and B during the
-• Lowered by androgens and in hypothyroidism
• The free and loosely albumin-bound steroids are menstrual cycle are different
believed to be the most biologically important o Inhibin B – rise rapidly on the day after the
fractions because the steroid is free to diffuse or intercycle FSH rise
be actively transported through the capillary Falls to a low concentration during
wall and bind to its receptor. the luteal phase
• The major sites of steroid metabolism are the o Inhibin A – rise only in the later part of the
liver and kidney. follicular phase and maximal during the
Non-steroid-
specific albumin
⑧Low affinity but high capacity for steroids midluteal phase
Unbounds or
“free” form -
Most biologically important
Endocrine Hormone Function o X -
Anovulatory cycles are most frequent during
fr
gland this period
-
O
Or
Anterior FSH • Stimulates follicular growth • Mean age of menarche = 12
Pituitary in ovaries • Menopause = 45 and 55
• Stimulates estrogen
- -
-
secretion (from developing

follicles
- O
v
LH • Surge causes ovulation
• Results in the formation of a
X C corpus luteum
O Ovaries Estrogen
X f
• Thickens uterine lining
(endometrium)
• Inhibits FSH and LH for most
⑧ of cycle
• Stimulates FSH and LH
o release pre-ovulation
d
Progesterone
-• Thickens uterine lining
(endometrium)
• Inhibits FSH and LH
r
*These processes occur in sequence, conferring in monthly

rhythm to the reproductive cycle.
Follicular Phase
·
Menstrual Cycle • Recruitment of&Cohort of Antral Follicles
• The menstrual or ovulatory cycle involves a remarkable • Selection of Dominant
-
Follicle
coordination of morphologic changes and hormonal • Growth of Selected Dominant Follicle
secretions occurring not only at several levels of the
hypothalamic-pituitary-ovarian axis, but also in organs Recruitment of Cohort Of Antral Follicles
outside this main axis – like the uterus and the cervix. • FSH – provides the critical signal for the recruitment of a
• This sequence of events occurs in a cyclic process in a
monthly interval.
⑧
cohort of preantral follicles
o Major survival factor that rescues the follicles
from their programmed cell death (atresia)
• The initial stimulus from the brain under the form of and allows them to start growing, increasing in
GnRH pulses is crucial to proper gonadotropin size and beginning to synthesize steroids
responses, which in turn instigate folliculogenesis, o Increase in the FSH:LH ratio recruitment of a
ovulation, and the formation of the corpus luteum. cohort consisting of about three to seven
• Essential to the coordination of these events is the secondary preantral follicles
communication between the ovaries and the
I
hypothalamic-pituitary unit through the hormonal • Ovarian reserve – antral follicles in the ovaries
o Determine the capacity of the ovary to
<E
feedbacks, which provide continuous information of
the ovarian status to the brain, which in turn responds provide oocytes that are capable of being
with the proper pattern of GnRH pulses and of fertilized
gonadotropin release. o Determination: important tool in the treatment
• Humans are spontaneous ovulators (as opposed to light of infertility
or seasonally related) in that the gonadotropin surge, 1. Measurement of FSH on day 2 to 3 of the
the initiator of ovulation, is triggered by the cycle: Higher FSH levels denote ovarian
endogenous changes in estradiol that accompany the aging fewer recruitable follicles
maturation of the follicle. 2. Sonographic antral follicle count
3. Measurement of inhibin B on day 2 to 3
• Divided into two phases: of the cycle
oa Follicular phase o Provide an early indicator of the
number of recruited follicles and
↑ 00
o Luteal phase
• Mean duration 28 ± 7 days of their secretory activity
• Life span of corpus luteum = 14 days
•
0
Menstrual cycle length – most variable in the 2 years
following menarche and preceding menopause
- -
4. Measurement of anti-mullerian hormone o Stimulation by FSH of its receptors activates the
(AMH)/MIS (Mullerian Inhibiting production of the enzyme AROMATASE – responsible of
or
Substance) the biosynthesis of estrogen within these cells
• AMH is a secretory product of o Important change in the structure of the mature follicle:
granulosa cells in preantral and in acquisition of the theca cell layer (outermost layer)
small antral follicles. which surrounds the granulosa layer and rapidly
• O
Together with other factors, AMH differentiates into theca interna and theca externa
appears to inhibit the initiation of o The theca layer rapidly becomes well vascularized (in
premature follicle growth. ~
contrast to the granulosa layer, which remains
• o
AMH levels decline
-
with age, in avascular) through an active angiogenesis process,
parallel with the reduced follicle characterized by the presence of several vascular
pool. growth-promoting proteins such as vascular endothelial
• In the-treatment of infertility, the growth factor (VEGF), which stimulates growth of new
measurement of AMH in conjunction blood vessels.
V
with sonography offers a more
useful assessment of ovarian reserve
o Circulating FSH now stimulates LH receptor synthesis
within stromal cells of the theca interna.
and a better correlation with the o LH, in turn, promotes steroid biosynthesis by theca cells
-
number of oocytes retrieved than and the production of androgens.
that provided by FSH measurement. o These androgens, following diffusion into the granulosa
• O
Unlike FSH, AMH may be measured layer where the enzyme aromatase is located, are then
at any time of the menstrual cycle, biotransformed into estradiol.
with minimal variation. o This leads to an overall increase in estradiol production,
• OAMH is increasingly used in clinical
practice to identify women with
increased intraovarian estradiol levels, and increased
estradiol secretion into the peripheral circulation.
premature ovarian insufficiency or o As the dominant follicle grows, an antrum (cavity) forms
PCOS; into which follicular fluid accumulates. This fluid
o Very high levels of AMH contains several steroids, peptide and protein
may reflect PCOS hormones, and nutrients.
Selection of Dominant Follicle OVULATORY GONADOTROPIN SURGE AND OVULATION

-
• Only one dominant follicle • Maturation of the dominant follicle is marked by high
•
o Other follicles in the cohort became atretic
Process of selection is completed by day 5 of the
< blood levels of estradiol
ACTIVATION OVULATION
positive feedback loop
follicular phase • LH levels increase 10-fold over a period of 2 to 3 days &

• Process of selection most probably reflects the FSH levels increase about 4-fold
competitive advantage of the dominant follicle, o Absolute requirement for the final maturation
characterized by a well-vascularized theca layer, of the oocyte and the initiation of the follicular
allowing a better access of the gonadotropins to their rupture
target receptors results in a greater local estradiol • Fully gown oocyte resumes meiosis (meiotic maturation)
secretion, which in turn increases the density of o Diplotene stage (1st meiotic division)
gonadotropin receptors and promotes cell metaphase II (second meiotic division)
multiplication. o First polar body appears
• At the same time, elevation of peripheral estradiol o
@
Second meiotic arrest – only be completed at
levels will activate the negative estradiol feedback
loop and result in a decrease in circulating FSH to a
Ovulation (Follicle Rupture)
v
the time of fertilization
concentration insufficient to sustain growth in the other

follicles of the cohort. • Occurs about 32 hours after the initial rise of the LH
• In addition to estradiol, granulosa cells of the recruited surge and about 16 hours after its peak
follicles also secrete inhibin B = selectively suppresses • LH surge induces an acute inflammatory-like reaction
FSH secretion, further decreasing the stimulus to o Interleukins, cyclooxygenase
maturation. o Prostaglandins – induce the hyperemia and
• The dominant follicle, however, continues to grow edema
because of its greater density of FSH receptors and o Proteolytic cascade – involves collagenases
greater vascularization of its theca cell layer, allowing and plasminogen activator leads to the
more FSH to reach its receptors. degradation of the follicular layers and wall
follicle rupture
Growth of the Dominant Follicle Plasmin helps in detaching the
cumulus cell-enclosed oocyte from
the granulosa cells, which initiates
the process of extrusion of the
oocyte and cumulus when the
follicle ruptures
Luteal Phase
• O
After the oocyte is extruded from the mature dominant
-
follicle, the amount of follicular aid is markedly
reduced, the following wall becomes convoluted and
the follicular diameter and volume greatly decrease
corpus luteum
o
granulosa cell layer a
FSH receptors are located within the avascular
a
N • The corpus luteum is the result of two impt events
initiated at ovulation:
First:
N
o
Granulosa and theca cells hypertrophy, TWO MAJOR LAYERS OF THE ENDOMENTRIM
take up increasing amounts of lipids and 1. Stratum Basale
acquire organelles associated with • Lies on top of the myometrium
steroidogenesis • N Primordial glands and densely cellular stroma
Hallmark of the human corpus luteum • Change little during the menstrual cycle and do not
secretion of progesterone desquamate at menstruation
Significant amounts of inhibin A are also
produced. 2. Stratum Functionale
o OSecond:
The basal lamina, which separated
•
•
Lies between the basale and the lumen oo the uterus
Composed of 2 layers – stratum compactum and
- the granulosa and theca cell layers, stratum spongiosum
-
is disrupted, and capillaries from the
theca interna now invade the
•
UAffected by hormonal changes
S
granulosa layer (which up to now
had been avascular) to form an
•
⑪ Stratum Compactum – O neck of the glands and densely
populated stromal cells
extensive capillary network.
~
o
o
Superficial layer A
Serves as the site of the blastocyst
• Like the dominant follicle, growth and development of implantation and provides metabolic
the corpus luteum occur rapidly. Vascular growth plays environment
a central role in this process.
• Angiogenic factors, such as vascular endothelial
growth factor (VEGF), are present in high quantity in the ②
• Stratum Spongiosum –O
glands with O less populated
stroma and large amounts of interstitial tissue
forming and developing corpus luteum. o Maintains the integrity of the mucosa
Corpus Luteum Regression (Luteolysis)

• a
Lifespan of corpus luteum – 14 days
• ⑧
Reaches maturity 8 to 9 days after
-
ovulation
•
ODecline in estrogen, progesterone and inhibin
o Only rapidly rising concentrations of chorionic
gonadotropin (hCG) [secreted by the
syncytiotrophoblast] following conception
can rescue the corpus luteum and maintain
the production of progesterone
• Structural luteolysis – complex process responsible for
the elimination of the corpus luteum
Intense cytoplasmic vacuolization and
N
o
invasion by macrophages
o Degradation of the luteal cells terminates in a
v perimenstrual apoptotic wave, and
menstruation follows ovulation by 13 to 15
days, unless conception has occurred (“the
missed menses”)
MENSTRUAL CYCLE AND THE ENDOMETRIUM
o Integration and synchronization between cyclic

changes within the hypothalamic-pituitary-ovarian axis
and the endometrium is an essential prerequisite for
viable reproduction.
o The primary goal is to ensure an appropriate
environment for the implantation of the developing
conceptus.
A
ENDOMETRIUM IN THE PROLIFERATIVE (FOLLICULAR) PHASE • Regular Menstruation
•
•
N
Endometrium – 1 to 2 mm thick
Consists mainly of the Stratum Basale and a few glands
o Duration: 3 to 5 days
Anywhere from 2-8 days is normal
me Menstrual intervals vary depending
on the age and time of initiation of
• Stratum Functionale proliferates greatly by the pre-menopause period
multiplication of both glandular and stromal cells o Average blood loss: 10 to 80 mL (Ave 35 mL)
• Late Follicular Phase – straight glands become A similar volume of
progressively more voluminous and tortous
J nonhematogenous fluid is also shed
during menstruation.
ManyO women also notice shedding
I
• LH surge and before ovulation subnuclear vacuoles of the endometrial lining that
-
appear at the base of cells lining the glands (first appears as tissue mixed with the
indication of an effect by progesterone) blood = may be erroneously thought
• Sonography: 4 mm in the early follicular phase 12 to indicate an early term miscarriage
mm at the time of ovulation of an embryo
⑧
The enzyme plasmin tends to inhibit
ENDOMETRIUM IN THE SECRETORY (LUTEAL) PHASE the blood from clotting.
• Proliferative endometrium undergoes a rapid secretory Because of the blood loss,
8
differentiation premenopausal women have higher
• Well-developed subnuclear glycogen-rich vacuoles dietary requirements for iron to
appear in every cell of a given gland prevent iron deficiency.
• Peak of intraglandular content and its release into the
lumen coincides well with the arrival of free-floating MENSTRUAL CYCLE AND THE CERVICAL GLANDS
blastocyst, which reaches the uterine cavity by about • Cervix – plays a substantial role in fertility
3.5 days after fertilization o Changes in the production and property of
o Provides energy to the energy-starved free- mucus corelated to changes in estradiol
floating blastocyst and progesterone during the menstrual cycle
• “receptive endometrium” o Enhanced production of cervical mucus +
o
of a 28-day menstrual cycle
a
Window of Implantation (WOI) – days 20 to 24 presence of crypts within the endocervix
facilitate the transport and storage of
o Implantation occurring about 1 week after spermatozoa around midcycle
fertilization
• Stroma becomes more~ edematous as a result of • Cervical mucus – copious amounts high estradiol
increased capillary permeability levels at the end of the follicular phase
• Endothelial proliferation results in the coiling of o Clear, water-like appearance, which is
capillaries and vessels A acellular
• Predecidual stromal cells – precursor forms of o “Fern” when it dries as viewed under the
gestational decidual cells microscope
“Stringy” referred to as “Spinnbarkeit” (i.e.,
A
o Nongestational endometrium they are o
-
engaged in phagocytosis and digestion of cervical mucus that can stretch on a slide at
extracellular collagen matrix least 6 cm
↑O
o Pregnancy secrete prolactin o Signifies the “fertile period”
Control the invasive nature of the
• Cervical mucus – thick high progesterone
-
normal trophoblast
--
In their absence, the trophoblast o Less conducive for sperm transport thus
providing a contraceptive effect = ”minipill”
may invade the myometrium
leading to placenta accreta
o Clinically, the measurement of hormonal
*
levels in parallel with the use of quantitative
morphometric endometrial measurements
produce a significant correlation with
chronologic dating of the length of the luteal
phase. -
o Clinical dating of the endometrium, however,
-
v
-
- >
is somewhat subjective and is rarely carried
out today.
o Sonography – endometrial thickness is at 8 to
14 mm – thickness remains throughout the
luteal phase
MENSTRUATION
• If implantation of the blastocyst does not occur in the
late luteal phase and hCG is not produced to maintain
the corpus luteum, the endometrial glands begin to
collapse and fragment.
• Endometrial glands begin to collapse and fragment
• Polymorphonuclear leukocytes and monocytes infiltrate
the glands and stroma autolysis of the stratum
functionale desquamation loss of integrity of
blood vessels destruction of endometrial interstitial
matrix bleeding
HORMONE ASSAY TECHNIQUES Mass Spectrometry Assays
• Ability to measure large numbers of structurally similar
• Immunoassays compounds
o
o ·
Much faster
f
Much easier to perform
Much enhanced
•
•
High specificity, sensitivity and throughput
Most powerful assay method for defining defects in
o
- 0 sensitivity steroid hormone metabolism
o
I 0
Require far less than 1 mL of serum or plasma • Routine analysis of steroid hormones in major clinical
diagnostic laboratories
1. Preparation of Antibodies
• Production of availability of an antibody to the
analyte to be measured
o Polyclonal antibodies – produced

following theO
injection of the hormone in
- - -
larger animals such as sheep or rabbits

- -
Protein hormones – host will produce

polyclonal antibodies against the
hormone
m
D
Steroid hormones – too small to
produce immune reaction on their
own (haptens) and are not
recognized as foreign because they
are the same in most species
May “cross-react” with other closely

related hormones
Lack specificity to the concerned
hormone
o Monoclonal antibodies – provide unique

specificity by recognizing only one
epitome (antigenic determinant)
2. Choice of Assay Markers

• Availability of a labeled analyte (hormone) in
the competitive immunoassay or a labeled
second antibody to the analyte in a reagent
excess immunoassay
o Labels
Radioactive, such as Iodine I125
Enzyme immunoassays (enzyme-
linked immunosorbent assays, or
ELISA; immunometric assays)
Chemiluminescent immunoassays
(CIA)
Fluorimetric Immunoassays (FIA)
3. Separation of Bound and Unbound Antigen

• Antibodies can be attached to solid surfaces
such as to plastic tubes, beads or plates, or
cellulose particles
• Separation:
o Washing of the unbound antigen
o Use of a second antibody-label conjugate
Assay Evaluation
• When evaluating the value, accuracy, and relevance
of an assay, four items must be examined:
o ⑧
Sensitivity – measures the least hormone that
can be measured with accuracy. This will set
the lower limit of the assay
o Specificity – ability of the assay to measure
o
⑧
only the specific hormone of interest
Accuracy – ability to measure the exact
I
-
amount of the hormone present in the sample

- -
- > >
o Precision – ability of the assay to consistently
reproduce the same results -
=
Gynecology Congenital Abnormalities
AY 2021-2022 Renna Cristina B. De Leon, MD, FPOGS, FIFEPAG
1st Shift
08/27/2021
OUTLINE
I. Introduction IV. Hymenal Anomalies  In newborns with ambiguous genitalia, a range of abnormalities
II. Ambiguous Genitalia A. Imperforate Hymen involving the clitoris, urethra, labia, and introitus can be
W W w -
A. Disorder of Sexual V. Mullerian Anomalies identified, and immediate evaluation is necessary.
Development VI. Vaginal Agenesis  Disorder of sexual development (DSD)
B. Labial Fusion A. Androgen Sensitivity  In utero androgen exposure (too much or too little) ➡️
III. Perineal and Hymenal VII. Transverse Vaginal development of external genitalia.
Anomalies Septum  46, XX DSD - females with masculinized or virilized external
A. Clitoral Anomalies VIII. Vaginal Adenosis genitalia.
B. Bifid Clitoris IX. Abnormalities of the Cervix  46, XY DSD - males with undervilized external genitalia.
C. Labial Fusion X. Abnormalities of Uterus
D. Ovotestes Abnormalities of the Ovary A. 46, XX DSD
E. Congenital Adrenal  For females, the timing of antenatal (embryonic) exposure to
Hyperplasia androgen influences the degree of masculinization.
 The vaginal plate separates from the urogenital sinus at
a
I. INTRODUCTION X O
about 12 weeks of fetal development.
O  Androgen exposure before 12 weeks ➡️ labioscrotal

- Congenital abnormalities of the female reproductive tract are
common and can affect external genitalia and müllerian structures.
N ➡️ creates a
fusion and retention of the urogenital sinus
f
 Causes: ⑧
single tract that the urethra and vagina empty into before
reaching perineum.
of
 Genetic errors
-
 Teratogenic events during embryonic development  Androgen exposure after 12 weeks ➡️ clitoral hypertrophy
- -
- -
 Minor abnormalities may be of little consequence

 Major abnormalities ➡️ severe impairment of menstrual and
reproductive functions ➡️ associated with anomalies of the
urinary tract.
 Present during:
 Birth prefer
II
 Before puberty *
 Onset of menses I
 Pregnancy with adverse pregnancy outcomes
 Some are asymptomatic
DSD = d
-
 Incidence: 1% to 3%  Possible causes of& 46, XX DSD include congenital adrenal

hyperplasia, other genetic mutations that affect the steroid
II. AMBIGUOUS GENITALIA pathway, maternal ingestion of androgens, or maternal
production of excess androgens.
a
After delivery of the neonate, the obstetrician is often the
-
 In the past, gender was assigned primarily on the principle of
"phallic adequacy" with neonates with an ambiguous phallus
-
provider who identifies the gender of the neonate.

 a more detailed assessment of the neonate's genital anatomy is being assigned female gender.
necessary. --  Current approach is to initiate a thorough evaluation of the
 Observe the newborns perineum: neonate and to defer assignment until the clinical picture is
 Mons pubis clear.
a
 Clitoris - noted for any obvious enlargement
- mmm
B. LABIAL FUSION
A
 Opening of the urethra
W
A
 (+) palpable gonads in the inguinal canal, labioinguinal
a
 Labia - should be gently separated to see if the introitus can
N
O
region, or labioscrotal folds = testes ➡️ male with ambiguous
men
be visualized.
 genitalia
-Introitus
 Hymen - perforate, revealing the entrance into the vagina -
 (-) palpable testes in the scrotum ➡️ virilized female
~ adrenal hyperplasia A
- -
 Rectum - posterior to the perineal body, should be tested to  Most often the result of congenital
-
check
-
be sure that is perforate.  Rectal examination - may allow palpation of the cervix and
rectal - A
·
 Meconium staining around the rectum is evidence for uterus
empeadie
*
X
perforation. ]  Help in gender assessment
 If there is doubt, the⑧rectum may be penetrated with a  Bifid clitoris and labial fusion - usually associated with
> N
moistened cotton-tipped swab.
- >
extrophy of the bladder
O
 Inguinal area – palpation for any masses is also important
- - -
- -
eNDL Excelsus 2023 1 of

10
 As with any congenital anomaly, the neonate should be  Extreme cases of androgen stimulation are generally associated
thoroughly evaluated for other congenital anomalies. with fusion of the labia.
 These findings occurring infants with congenital adrenal
 Karyotyping
~
 The initial evaluation of ambiguous genitalia involves checking:
Female 4xx
hyperplasia and in those in utero to exogenous or endogenous
androgens (see figure 11.3)
made PIXt
 Transabdominal pelvic ultrasound  Similar in appearance, males with partial androgen insensitivity
 Serum electrolytes – to rule out congenital adrenal syndrome have underdeveloped male external genitalia and a
hyperplasia small phallus hat appears as clitoral hypertrophy (Fig. 11.4)
 Steroid hormone levels
 Cystoscopy and vaginoscopy - can be performed with a
pediatric cystoscope to assess the pelvic structures,
including the location of the urethra and vagina and the
on
presence of a cervix. One only
connection a rain
stems
B. BIFID CLITORIS
 Is usually seen in association with extrophy of the bladder.

 Extrophy of the bladder occurs rarely (1 per 30,000 births) and
has male predominance (3:1)
penpalet  When it occurs in females, it is often associated with a bifid
clitoris.
 Approximately half of female patients with bladder extrophy may
-
-Orquan turp
have associated reproductive tract anomalies such as vaginal
anomalies and müllerian duct fusion disorders.
N
 Anterior rotation and a shortening of the vagina with labial
fusion are quite common.
deeration
mitiate
thorough C. LABIAL FUSION
Female on<lg
III. PERINEAL AND HYMENAL ANOMALIES  May occur without clitoromegaly (46, XX DSD or 46, XY DSD)
 True hermaphrodite - ovotesticular DSD - has both - ovarian
A. CLITORAL ANOMALIES (including follicular elements) andO
testicular tissue, either in the
same or opposite gonads.
A


Normal clitoris -1 to 5 cm long and 0.5 cm wide
>
The glans is partially covered by a hood of skin.
D. OVOTESTES
 The urethra opens near the base of the clitoris.


Enlarged because of androgen stimulation.
In such circumstances the shaft of the clitoris may be quite vO
 Present in individuals with ovaries that usually have a SRY
Wantigen present and testicular tissue present.
--
enlarged and partial development of a penile urethra may have  Ovulation and menstruation may occur if the müllerian system is
occurred.
A appropriately developed.
 Spermatogenesis may occur as well
⑧
 Testicular tissue is present ➡️ increased risk for malignant
adegeneration
 Treatment: gonadectomy after puberty
 Ovarian portion ➡️ Germ cell tumors, such as gonadoblastomas
and dysgerminomas Lo
A
Gyne Congenital Abnormalities 2 of

10
E. CONGENITAL ADRENAL HYPERPLASIA IV. HYMENAL ANOMALIES
+
21-hydroxylase deficiency &are aldistance coifyol
A. IMPERFORATE HYMEN
aMost common form (inborn error of metabolism)
 Inability for the central cells of the hymenal membrane to
Autosomal recessive gene coded on chromosome 6 A
Ne
Severe mutation - major biosynthetic pathway to cortisol is
dissolve during late fetal development to establish a connection
between the lumen of the vaginal canal and the vestibule.
blocked (17 OHP is produced)  1 in 1000 live-born females
 11 - hydroxylase deficiency  Hydrocephalus/mucocolpos- fluid or vaginal secretions build
 36- hydroxysteroid dehydrogenase deficiency up in neonates or infants I
O
 Birth ➡️ presence of ambiguous genitalia in 46, XX individuals
mm
 75% - homozygous for CAH mutation - at risk for the to
due
development of a life-threatening neonatal adrenal crisis
(sodium loss because of lack of aldosterone production) withdrawal
 Milder disease - accelerated bone maturation
materingent
 Development of premature secondary sexual characteristics in
- males
a
 Virilization in females
-
 Screening: 17- OH progesterone level
hydroxy
*
masculliation
 PRIMARY AMENORRHEA -
r Hematometra X
 Symptoms collection
cnamemueaimperpura
 Cyclic cramping but no menstrual flow
W -Hematocolops blood filled dilated
nepwer O
raging
cotrection of blood in
ragile
external g Pelvic pain of blood in utens
I
op - Urinary retention
generally v Difficulty with bowel movements
 Retrograde menstruation - menstrual blood may distend the
-
fallopian tubes and form endometrial implants in the peritoneal

cavity.
 Physical Examination
anuaem
 Bulging membrane with a bluish hue is appreciated at the
-
introitus
rate
 Palpable vaginal mass - rectal exam
->
 Treatment
 Replacement of cortisol  Treatment
I diagure
 Suppress ACTH output ➡️ decrease stimulation of the in  Surgery: Cruciate incision ➡️ hymenectomy, hymenotomy
-
cortisol producing pathways of the adrenal cortex ➡️

decrease androgen production
->
 At risk: offer Antenatal therapy
 Diagnosed with CAH
CAH,
children
Yanae
 Have had children with CAH
 Pregnant patient (at risk)
H Benose
 Daily administration of dexamethasone (suppress fetal
o adrenal glands until the fetal gender can be verified with

prenatal diagnosis)
N  Female infants exposed to high levels of androgens in

-
utero may need corrective surgery
N  Follow-up vaginoplasty (due to vaginal stenosis)
-
-  Psychological support and counseling

10
V. MULLERIAN ANOMALIES  46, XX karyotype -female
 Primary amenorrhea a users
-
-
 Congenital anomalies of the female reproductive tract

tr Defects in development of the Mullerian ducts
-Cxx,
xihysicalcharacted
 Embryology
 Genetic sex- determined during fertilization
g
aPhenotypic sex - after the sixth week of development

 3rd and 5th week - both the wolffian (mesonephric) and
Mullerian (paramesonephric) ducts are->I
-
present
i
O
 Complete vaginal agenesis - 75% of women with MRKH
syndrome
O
 Short vaginal pouch - 25%
 Ovaries are normal and the fallopian tubes are usually present
 Concurrent anomalies
 50% - urinary tract anomalies
 Renal agenesis, pelvic kidney, multicystic dysplastic
kidney, and ureteral duplication
 12% - skeletal anomalies
 Congenital fusion or absence or vertebrae C
>--
 Cardiac defects and hearing loss

 Physical Examination
 Absence of a vaginal opening/presence of a short vaginal
pouch
 Rectal examination uterus not palpable
 Primary amenorrhea and a distal vaginal obstruction

 Differential diagnosis
Person
Just IVaginal agenesis > Vertical
gate, fate
⑭
mulleran duet  Transverse vaginal septum
-
 Imperforate hymen
 Anomalies of Mullerian duct development
in the midline 2
-Androgen insensitivity syndrome CareD PX
 Three categories of disordered duct development f A Hormones- normal levels
①  Agenesis and hypoplasia
I
-
 Karyotype- 46, XX
i
not reach
 Lateral fusion defects  Ultrasound
②  Most common crogental - -
examination - presence of normal ovaries and the
absence of the uterus
 Failure of migration of one or both ducts Drous,
- -
A
 Midline fusion of the ducts
-
 Absorption of the midline septum between the ducts.
A. ANDROGEN SENSITIVITY <malel
canancation (they we(
O nee
②
 Vertical fusion defects NOT a Mullerian anomaly
 Disordered fusion of the Mullerian ducts with the  46, XY karyotype - defective androgen receptors r
urogenital sinus or abnormal vaginal canalization  Testicular feminization syndrome
(menstrual flow obstruction) d  Developing fetus cannot sense any testosterone
 DES-induced anomalies a
in
 External genitalia are feminized
alor
 In utero exposurecrarel - Short vaginal pouch
Cant nounel)
-
 Testicular production of AMH multenal
VI. VAGINAL AGENESIS  Mullerian ducts resorb and the wofflian duct derived tissue
open - -
--
 Aka Mullerian agenesis or Mullerian aplasia or Mayer- persists. ---
respite
cell t
Rokitansky-Kuster-Hauser (MRKH) syndrome
 Failure of Mullerian duct development or marked aberrations in
 Lack of functional androgen receptors
Y Testes remain undescended is
androgen
v - -
the typical steps of Mullerian development -  Undergo normal pubertal development ➡️ testes ➡️ testosterone
=>
 Congenital absence of the vagina and variable development of ➡️ aromatized to estrogen ➡️ without functional androgen
Fthe uterus
receptors ➡️ no testosterone action
 1 in 5000 females
~ U
 Phenotypic females - primary amenorrhea, tall and have
 Normal pubertal development
sparse to no pubic hair.
 Normal ovarian function
aca
between 5 to non
10
-
meen Ale
-
will
 Estrogen induced growth spurt ➡️ remove the undescended  Complete septum
testes ➡️ prevent the development of a gonadoblastoma  Can lead to hemocolpos and hematometrium
 Differential diagnosis
bulging
conpri)
- -
 Treatment of Vaginal Agenesis

- -
 Imperforate hymen no
-
 Psychological counseling  However, in transverse vaginal septum the- obstruction is
-
 Creation of a neovagina for future sexual function higher in the vagina, the O
septum is made of thicker tissue
and there is no bulging tissue at the introitus
 Achieve motherhood ➡️ gestational carrier / adoption
 Clinical manifestation:
 Creation of a neovagina
g Primary amenorrhea
 A. Nonsurgical option: vaginal dilators (Frank method)
 Cyclic cramping
 Daily use of dilators➡️ 15 to 20 minutes (3 to 6 months I
 Worsening pelvic pain
or longer) a
 Partial/perforate Transverse Septum
 They usually menstruate but can develop hematocolpos over
A time along with foul smelling vaginal discharge
 There could be e reports ofr-
normal menstrual
--
function but
inability to insert a tampon or have intercourse
w h e re
 It is often less than 1 cm thick but sometime can be more

mum
than 2 cm thick
TREATMENT OF TRANSVERSE VAGINAL SEPTUM

 Thin transverse vaginal septum or perforate transverse
vaginal septum:
 B. Surgical option
 Septal tissue is excised and the proximal and distal vaginal
O
&
 Goal: develop the potential space between the bladder crun
ow
we
tissue are sutured together ➡️ normal vagina

and the O
- - -
rectum and insert into this space a new tissue

 Thick vaginal septum:
that will develop into a vagina.
o Split-thickness skin graft  Septum is excised ➡️ tissue graft may be needed to bridge
- hmme
o Buccal mucosa the distance between the proximal and distal vaginal tissue
o Peritoneum edges
o Bowel (sigmoid or small bowel)  With all these reconstructive surgeries, female may need to
m
more
or
o Synthetic tissue grafts wear a stent or dilators to prevent scarring and narrowing at the
--
surgical site.
VII. TRANSVERSE VAGINAL SEPTUM
VIII. VAGINAL ADENOSIS
a
 Occurs in females who was exposed to DES (diethylstilbestrol)
in utero
 The junction of the müllerian ducts and sinovaginal bulb may
not be sharply demarcated
 If müllerian elements invade the sinovaginal bulb ➡️ adenosis
in the adult vagina
 Vaginal adenosis is generally palpated submucosally,
although it may be observable at the surface
IX. ABNORMALITIES OF THE CERVIX
 Cervical anomalies can occur along with0

amer
0
uterine and vaginal
anomalies or can occur in isolation
transverse vaginal septum  If one or both of the müllerian ducts do
- -
not fuse, do not develop,
aum
or develop incompletely, cervical duplication or agenesis can
- - -
 Occurs due to partial canalization of the vaginal plate leaving a

occur
- band of tissue across the vagina.
 Its septum can either have a partial (perforate) or complete
-
- -  Cervical Duplication
septum.
 Can result in
O
 Most commonly lies at the junction between the upper 3rd and
- -
W  2 separate and distinct cervices or

lower ⅔ of the vagina
-
--
--
 Incidence: 1 per 75,000 females Cravel a 2 cervices that are fused in the midline
 Partial transverse vaginal septa are reported in females a
 A septate cervix can occur when the midline septum
A  There is no obstruction of menstrual flow
exposed in DES (diethylstilbestrol)
 This diagnosis is rarely made in prepubertal stage unless there A
is development of mucocolpos and mucometrium behind the
septum and unexplained abdominal mass.
10
 Cervical Agenesis and Hypoplasia
 Occur due to incomplete or absent duct development and
often present with
 Obstructed menstrual flow with associated
 Cyclic or chronic pain
 Hematometra
 Diagnostics
 Ultrasound
 MRI
 Management
o
 Long-term menstrual Suppression with Hormones Comparison b/w MRI and 3D US
 Cervical Reconstruction Legend: A, Unicornuate; B, Bicornuate; C, Complete Septate with 2 cervices; D, Partial
Septate; E, DES related
 Hysterectomy
 Signs and Symptoms
 Exposure to DES (diethylstilbestrol) can lead to other cervical  Primary Amenorrhea
anomalies:
 Cyclic Cramping
 Hoods
 Dysmenorrhea
 Collars
 Hematometra - A blood accumulation in the uterus
platedo
 Adenosis
 Retrograde Menstruation -I
-
interner
backflow of menstrual blood
 Endometriosis - presence of endometrial glands and stroma
X. ABNORMALITIES OF UTERUS I
outside the uterus. It is common finding in women with
 Abnormalities of the uterus are categorized as lateral fusion obstructive and nonobstructive müllerian anomalies.
rerhasen,
defects and occur due to disordered duct fusion and septal
- -
- -
 Abnormal bleeding can also occur with uterine anomalies

- -
resorption
 American Fertility Society Classification (straightforward tentat and has been associated with septate uteri.
classification system of uterine anomalies based on

embryologic origin) (Figure11.13) o ryren Congenital Uterine Anomalies that are associated with increase
Poor Obstetric Outcomes:
 Denote Anomalies with Developmental Failure in one or both aRecurrent pregnancy loss (RPL): 12 - 16%
~
müllerian ducts
 Category I (Hypoplasia/Agenesis)
W
<small very (  First and Second - Trimester Pregnancy Loss: 25%
a
-Intrauterine Growth Restriction
 Category II (Unicornuate) - may occur in isolation or be
 Preterm Labor and Delivery
Neassociated with a contralateral rudimentary uterine horn
falline of
a
 Placental Abruption
that may contain functional endometrial tissue. idevelopment -
one or both  Malpresentation
 Describe Anomalies involving a Varying Degree of Failure of
midline Fusion.
mulieran
alup

-
-Intrauterine Fetal Demise Cstbrph]
 Category III (Didelphys) - commonly seen with a aCervical Incompetence
 Pregnancy - Induced HTN (d/t renal anomalies)
Nduplicated vagina, and this presents similar to a 2
longitudinal vaginal septum. Some cases, the vaginal aAnte - and Postpartum Bleeding
②
septum obstructs one side of the duplicated system,
causing a female to present with worsening pain during  Uterine Dysfunction is due to:
menstruation due to hematocolpos and Hematometra on ra
Decrease cavity size
the obstructed side. v-
Impaired ability to distend
 Category IV (Bicornuate) - can present with a single  Abnormal Myometrial and Cervical Function
- e m -e
cervix or a duplicated cervix, and a longitudinal vaginal  Inadequate Vascularity
septum can also be present. craial)
w
 Abnormal Endometrial Development septateateascommon
a most
-
 Identify Anomalies with Some Degree of Failure of
a venate items
i
Resorption of the Midline Septum  Diagnosis:
intermemor
yourever
 Category V (Septate) - present with a single, septate, or  Diagnosis of a uterine anomaly may be indicated by an
duplicated cervix and may also occur with a longitudinal individual's history, suggested by physical examination,
vaginal septum confirmed with pelvic imaging
 Category VI (Arcuate)  Depending on the population studied and the quality of the
 DES (diethylstilbestrol) imaging, either the arcuate uterus or the septate uterus is the
2p
 Category VII (DES Drug related) most common uterine anomaly
 Classification by Toaff (Figure 11.14)

 Imaging:
s a
 MRI is able to assess more complex müllerian anomalies
that may involve the uterus, cervix, and vagina, and
simultaneous assessment of the urinary tract is possible
O
 MRI is the gold standard  Rarely necessary to perform surgery to diagnose a uterine
(multenan
>
 3D ultrasound anomaly. It must be emphasized that with müllerian
-
 2D ultrasound anomalies, the evaluation of the urinary tract is commonly
indicated to identify any concomitant abnormalities.
-
Gyne Congenital Abnormalities

convenes 6 of
10
MANAGEMENT OF UTERINE ABNORMALITIES: REVIEW QUESTIONS
 Surgical intervention is indicated for obstructive anomalies 1. Main complications of Hymenotomy – Risk for stenosis or re-
related to: - closure
- 2. How is hymenotomy done?
aPelvic pain
a. Incise the hymen without trimming and suturing the edges
 Endometriosis 3. What are the two incisions?
~
 Poor Obstetric Outcomes (RPL, Second Tri Loss, or Preterm a. Cruciate shape – (clock: 2-8, 10-4) not to injure the urethra
a
Delivery) - prior to surgical intervention, rule out first extra b. Cross shape
uterine causes 4. Case 1: A 16 yr. old female with no menstruation but there’s
 Goals of Surgery: already breast budding, presence of axillary & pubic hair
complains of abdominal pain monthly. On PE: hypogastric
① Restoration of Pelvic Anatomy mass.
② Preservation of Fertility a. Differential Diagnosis:
 Treatment of Pelvic Pain and Endometriosis  Imperforate Hymen
⑤ recurrent  Transverse Vaginal Septum
-
 Septate Uterus - amenable to surgical correction preques
is
b. Cause of hypogastric mass – there is an obstruction
causing menstrual blood to accumulate in the uterus
-- (hematometra) and vaginal canal (hematocolpos).
 Unicornuate Uterus - never considered operable
 Excision of a functional rudimentary uterine horn and the 3r c. On PE:
 Imperforate hymen - look for bulging or bluish
attached fallopian tube:
not membrane of hymen and upon DRE, there is a
-To prevent a horn or tubal gestation palpable extraluminal mass anteriorly.
-To treat hematometra and Pelvic pain jiday  Transverse vaginal septum – the mass is noted to be
2-3cm far from the introitus.
d. Insert oral gastric tube in the vaginal canal and feel for
new demure
·
 Bicornuate and Didelphys Uteri - considered operable in resistance or blockage and check the distance from the
selected circumstances introitus
e. If transverse vaginal septum is confirmed, request for a
 Metroplasty be Transrectal ultrasound and KUB ultrasound
 To unify a bicornuate or didelphys uterus, but it is only
5. What to do with a patient with ambiguous genitalia?
performed in certain patients with poor obstetric outcomes
a. Do thorough physical examination
b. Palpate for the gonads in the inguinal region (+ gonads =
 Cervical cerclage testes)
-
 To attempt to improve pregnancy outcomes in women with c. Do rectal examination to palpate button-like mass (cervix
uterine anomalies and a history of poor reproductive or uterus)
- d. Diagnostics:
outcomes.
 Karyotyping
 Transabdominal pelvic ultrasound
 Hysteroscopic Metroplasty:
 Serum electrolytes – In congenital adrenal hyperplasia,
 Correct a partial or complete there is salt wasting (low mineralocorticoids = increase
septate uterus ACTH) (low sodium and high potassium)
 Indicated for RPL or 2nd Tri  Cystoscopy & vaginoscopy
pregnancy loss 6. Who does the cystoscopy? – Pediatric neurosurgeon
 Live birth rates improve from 7. Who does vaginoscopy? – Pediatric gynecologist
8. Moms at risk of having a baby with congenital adrenal
50% ➡️ 80% hyperplasia
 Miscarriage rates decreased -a. Mothers diagnosed with congenital adrenal hyperplasia
from 45% ➡️ 15% b. Mothers who previously delivered babies with congenital
- adrenal hyperplasia
 Safe, simple and Excellent
 Treatment and Mgt:
postoperative results a) Give dexamethasone
a b) Corrective surgery (for babies)

c) Follow-up vaginoplasty (for adults)
XI. ABNORMALITIES OF THE OVARY
 Accessory Ovary 9. Case 2: A patient comes in with breast budding (breast tanner
 Excess ovarian tissue near a normally placed ovary and A pouch (vaginal dimple).
=
N pubic hair (tanner stage II). On PE: short vaginal
stage III),
connected to it. a. Differential Dxn:
 Incidence: 1 case per 93,000 patients -Mullerian Agenesis
NAndrogen Insensitivity
 Supernumerary Ovary b. Androgen Insensitivity – can palpate for gonads in the
 Third ovary is separated from the normally situated ovaries. inguinal area
- - c. Mullerian agenesis – in DRE, no palpation of uterus and
 Omentum or retro peritoneum A cervix
 Incidence: 1 case per 29,000 autopsies
*** Refer to Appendix for illustrations

10
d. Diagnostics:
a Pelvic Ultrasound
1. Mullerian – there is still ovaries but absent
cervix and uterus
2. Androgen insensitivity – no ovaries can be seen
 Karyotyping
1. Mullerian – 46 XX
2. AI – 46 XY
10. Where is the vaginal canal originate? – both the neurogenital
sinus and Mullerian ducts
11.
a
When it is completely formed? – 20 weeks – formation of
vaginal canal,
a uterus,r and cervix
-
12. Main problems with pxn with Unicornuate uterus –O failure
development
- - -
of one or both Mullerian ducts
13. Septate uterus/arcuate uterus - failure of resorption in the
- -
midline
- - septum
14. Diagnostics for pxn with Mullerian anomalies –
 MRI of the pelvis,
a
a 3D Ultrasound – cost effective
aKUB ultrasound
15. “Do not operate on unicornate except the non-communicating
unicornuate”
REFERENCES
Dr. De Leon’s PPT and Lecture
APPENDIX

10
Abnormalities of Ovary

10
10
GYNECOLOGY: EMOTIONAL ASPECTS OF GYNECOLOGY
EMOTIONAL ASPECTS OF GYNECOLOGY Diagnosis C I A
PPT and Comprehensive Gynecology 7th ed • refers to persistent Sadness or lack of interest of pleasure in
usual activities, lasting for at least 2 weeks
OUTLINE muw
• Symptoms such as;
v
mum
I
• Common Psychiatric Disorders ○ Changes in eating habits
a
V
• Sexual Function and Disorders ○ Trouble sleeping
•
•
Psycho social Issues
How the Physician Can Aid The Patient
F
○ Lack of energy and motivation
○ Poor memory or concentration
DEVELOPMENTAL ISSUES IN CHILDHOOD AND ADOLESCENCE o

○ Feelings of guilt, worthlessness, hopelessness and despair
○ In sever cases, it may lead to suicidal thoughts and attempts
• The Patient Health Questionnaire

-
CPHO7
○ is a useful screening tool for major depression
What builds self-esteem? ○ can be filled out quickly by the woman in the waiting room
• Positive reinforcement of the child’s worth as an individual or in the office prior to a visit
• Appropriate warmth and love ○ helps in identifying depression, monitoring effects of
Self esteem: Girls and women
O
treatment, and educating women about her own
• starting in childhood, they often are highly invested in characteristic symptoms of depression
maintaining relationships, caring for others, not being “selfish” in ○ Scores:
pursuing their own goals and desires, and striving for ideal 5- Mild, 10- moderate, 15 - moderately severe, 20 -
standards of appearance and behavior. severe depression
• These characteristics make it difficult, throughout - life, to
effectively and constructively express anger, be appropriately
-
assertive, and know or pursue individual goals, and they may

predispose girls and women to conditions such as depression and
eating disorders.
• The physician can help by recognizing these characteristics and
conditions early and providing support and referrals for mental
health treatment as needed.
Physical, sexual, or emotional abuse in childhood and adolescence
• can have serious consequences for the child’s development
•
a
Evidence of abuse must be addressed vigorously. The health care
professional should communicate to the child or adolescent that
she is a victim and is in no way responsible for what has
- to child protective
happened. Reporting - services may be legally
mandated.
MAJOR DEPRESSION
• -
Common in women
• O
Lifetime prevalence: 20-25%
•aTwice as common in women as in men
• One of the leading causes of functional impairment and disability
- • Cause of major depression is unclear
• Risk factors
○-Family history of depression
|| INSIGNIS 1
a Prior depressive episode
○ 1. Antidepressant Medication
-
○ Older age • FDA black box warning: Antidepressants can increase suicidal ideation,
- Environmental stressors
○ especially in adolescents and young adults due to increase in energy and
‒ Loss of relationships and loved ones motivation before improvement in mood
• Overall, antidepressants reduce depression and risk for suicide, but this
‒ Divorce
potentially serious side effect is another indication for close follow-up early
‒ Role transitions in treatment.
‒ Interpersonal conflicts Selective Serotonin Reuptake Inhibitor (SSRI)
‒ Medical illness Side effects:
‒ Feeling of being trapped in a stressful situation without a - GI symptoms
way to escape or cope - initial dizziness and headaches
○ Loss of a parent during childhood- important factor Sexual dysfunction- delayed orgasm or anorgasmia
K
•
⑧
The increased rate of depression in women starting at menarche
has also been thought to result from hormonal factors.
Citalopram •
•
>40 mg daily (>20 mg/day age 60 or higher)
Risk of QT prolongation
a C
- -
- • Withdrawal symptoms: GI symptoms, headache,
• There are clear increases in risk for depressive symptoms
dizziness and “electric shock” sensations
premenstrually, with some women only experiencing mood Fluoxetine • Long half life
symptoms at this time and others noting a worsening of • Minimize withdrawal
underlying depression in the week or two prior to menses. I • Strongest evidence base for treatment of major
•
--
The postpartum period is a high-risk time for depression and is depression in children and adolescents
-
the highest risk time in a woman’s life for psychiatric
8
Venlafaxine
V
• Associated with a dose related risk for gradual
onset of hypertension and blood pressure
hospitalization. There is also an increase in depressive symptoms Bupropion
at the time of menopause and the menopausal transition. enhancing effects of dopamine and norepi
• Increases energy
Differential Diagnosis • Insomnia, increased anxiety, headaches and GI side effects
• Adjustment disorder • Lowers the seizure threshold (>450 mg daily)
• Should not be used in women with a history of a seizure disorder or
○ Stress related
bulimia
○ Short-term emotional of behavioral response to a stressful
2. Psychotherapy
life circumstance Cognitive Behavioral - addresses the negative, distorted thinking
○ Depressive symptoms begin within 3 months of the onset of Therapy(CBT) - behavioral activation, or scheduling
the stressor activities, it provide sense of
○ Resolve within 6 months once the stressful circumstance accomplishment, mastery or pleasure
ends - exercise
○ Physician’s role: refer for short- term therapy or counseling Interpersonal Therapy (IPT) - addresses the life changes and interpersonal
• Persistent Depressive Disorder (Dysthymia) challenges that contribute to depression
○ Chronic, low grade depression - grief, conflicts in interpersonal relationships
• Marital or intimate partner
○ Symptoms, present more than half the time for at least 2
conflicts
years and no more than 2 months without depressive • Transitions in roles within work or
symptoms during that time the family
○ Best treatment: antidepressant medication and • Social isolation
psychotherapy • Lack of supportive relationships
• Depression Related to Drugs and Alcohol or Secondary to a
medical Condition
• Bipolar Disorder
○ Manic episodes - feelings of euphoria or irritability and
increased energy or goal- directed activity
○ Symptoms
‒ Decreased need for sleep
‒ Increased activity or agitation
‒ Talkativeness
‒ Racing thoughts
‒ Grandiose and unrealistic plans
‒ Impulsive and risky behavior
Treatment
Goal: complete, remission or resolution of all depressive symptoms
How to increase rates of remission?
• Close follow-up (visits every 1 to 2 weeks at first and every 2 to 4
weeks)
○ Allow early identification of side effects that decrease
adherence
• Patient education SUICIDE
• Tracking symptoms with a scale (PHQ-9) • Feared and tragic outcome of depression and other mental
health conditions
• Highest rates at ages 45 to 64 years
|| || INSIGNIS 2
• 12 to 25 suicide attempts per every suicide death • Psychiatric Symptoms:
• Risk factors: ○ Depression
○ Depression or other mental health disorders ○ Social difficulties
○ Substance use disorders ○ Sleep disturbance
○ Agitation
○ Prior suicide disorders
○ Poor emotion regulation
○ Family history of psychiatric or substance use disorders
○ Rigidity
○ Family violence including physical or sexual abuse ○ Obsessional thinking
○ Access to means such as rearms in the house ○ Compulsive behaviors
• All depressed women should be asked about suicidal thoughts ○ Difficult to treat
○ Feels hopeless ○ Feat of gaining weight
○ Thoughts that life is not worth living ○ Do not see their illness as a problem
○ Thoughts of ending her life ○ Frequently nonadherent to treatment
• Active suicidal thoughts and plans are a psychiatric emergency ○ Feel isolated and do not engage with treatment providers
○ Women should not be left alone ○ Have multiple relapses
○ Take her to the nearest emergency room • Best treatment:
○ Referral to multidisciplinary team (medical, nutritional,
psychological and psychiatric expertise)
EATING DISORDERS ○ Outpatient treatment: Gradual refeeding to achieve weight
Anorexia nervosa, Bulimia nervosa, Binge Eating Disorders gain
○ Hospitalization: acute, dangerous medical or psychiatric
• Eating disorders primarily affect younger people and have their complications
peak onset between the ages 10 and 19 Bulimia Nervosa
• More common in women than men
• Binge eating, combined with inappropriate compensatory
• Many young women with eating disorders are secretive about
mechanisms to avoid weight fain
their disorder, do not view it as a problem, and do not seek
○ Self induced vomiting
E
treatment for it.
○ Misuse of laxatives or diuretics
• Gynecologists may see such girls or women for related problems,
○ Fasting
such as amenorrhea, menstrual dysfunction, low bone density, -
sexual dysfunction, infertility, anxiety, depression, hyperemesis
○ Excessive exercise
• Binge eating and compensatory behaviors occur an average of
gravidarum, or other pregnancy complications
once a week for 3 months
• Because the woman may not volunteer information about
• Most common in young women
disordered eating, it is important to have a high index of
• May develop:
suspicion for eating disorders
○ Hypokalemia
○ Scoff
○ Hyponatremia
‒ Simple, five question self rating scale
○ Hypochloremia
‒ Highly sensitive and specific in detecting disorders
○ Metabolic alkalosis- vomiting
○ Metabolic acidosis- laxative abuse
• Recurrent self- induced vomiting
○ Loss of dental enamel
○ Parotid gland enlargement
○ Calluses and scars on the dorsal aspect of the hand
• Serious complications
○ Esophageal tear
○ Gastric rupture
○ Rectal prolapse
○ Cardiac arrythmias
• Treatment
○ Cognitive behavioral therapy
Anorexia ○ Interpersonal therapy
○ Dialectal behavior therapy focusing an emotion regulation
• Disturbed body image
• Fears of becoming fat or gaining weight ○ Family therapy
• Body weight is less than expected ○ Medications:
• Causes amenorrhea ‒ Antidepressants
a
• Weight loss ‒ Flouxetine: 60 mg daily - treatment of choice
○ Achieved by restricting food intake, over exercising, self- ‒ Bupropion- contraindicated in women with a
induced vomiting, or use of laxatives, emetics and diuretics history of bulimia, elevated risk of seizures
• Risk factors (electrolyte abnormalities)
○ WGenetics Binge Eating Disorder
○ WHistory of childhood sexual abuse • Woman binge eats- averafe of 1x a week for at least 3 months
○ W Psychological traits of low self-esteem, perfectionism, and
• Does not engage in compensatory behaviors:
obsessive thinking
- ○ Purging
• Prolonged QT interval- serious sequelae of anorexia nervosa and has
○ Fasting
been associated with sudden death
○ Excessive exercise
|| || INSIGNIS 3
•
• May also develop obesity BMI of 25 to 34.9 kg/m2 (waist circumference of over 35 inches)-
• Treatment associated with heart dse and DM
○ Nutritional consultation •
Because of these risk factors, ACOG recommend screening for
○ Diet obesity.
○ Physical activity •
Complicating factors:
○
○ Education Hypertension
○
○ Specific psychotherapies DM
○
‒ Cognitive-behavioral therapy Dyslipidemias
○
‒ Dialectical behavior therapy Heart dse
○
‒ Interpersonal therapy Stroke
○
○ Medication Arthritis
○
‒ Antidepressants- SSRIs Increased
‒ Weight loss agents- Topiramate operative
‒ Stimulants morbidity and
mortality
○
Compromised
pulmonary function (sleep apnea)
•
Obstetric and gynecologic problems:
○
Spontaneous abortion
○
Endometrial hyperplasia
○
Endometrial and breast cancer
•
Increased BMI and Cancer Risk
○
Endometrial cancer
○
Gallbladder cancer
○
Esophageal AdenoCa
○
Renal Cancer
•
Weaker Positive association:
○
Postmenopausal breast, pancreatic, thyroid and colon
cancer
○
Leukemia, multiple myeloma and non-hodgkin lymphoma
•
Treatment
○ Nutritionally appropriate limited caloric diet
‒ Utilizing a smart phone app for weight loss
‒ Avoiding food binges
‒ Avoiding eating at night
‒ Practicing stress reduction or mindfulness- based training
‒ Portion controlled servings of food
‒ Setting a realistic goat of 5% loss of body weight over 6
months is helpful
‒ tracking calorie intake
○ Exercise
‒ Very beneficial for long- term weight management and
overall health
‒ Medications for wight loss: recommended for
BMI >30kg/m2 or >27 kg/mg2
‒ ORLISTAT- inhibits dietary fat absorption. Can
cause fecal urgency, flatuence and oily stools
‒ Sibutramine- inhibits reuptake of
neurotransmitters and affects satiation. Can
cause increase in HR
‒ Lorcaserin (Serotonin 2C receptor agonist) -
reduces appetite
‒ Metformin
• Eligible candidates for bariatric surgery
-○ BMI >40 kg/m2
-○ BMI >35 kg/m2 w/serious comorbid conditions
○ Nonsurgical weight loss measures have failed
-
OBESITY ○ Woman is motivated and well -informed
○ Acceptable surgical risk
•
Strong relationship between mortality and increased BMI above a
25 kg/m2 and below 20 kg/m2
•
Even in healthy people who have never smoked, at age 50 years, Obesity in Adolescence
there is still an elevated risk of death for persons whose BMIs are • 17% of young people (2 to 19 y/o) are obese
between 25 and 30
|| || INSIGNIS 4
•
-
Being overweight in adolescence is a more powerful predictor of ○ General measures
morbidity from cardiovascular disease than overweight in ‒ Counseled to avoid exacerbating factors, such as caffeine,
adulthood. alcohol, stimulants, or other illicit drugs and to
• Treatment: examine possible modifiable sources of increased life
○ Combined behavior lifestyle modifications with dietary stress
changes ○ Medication
○ Physical activity ‒ SSRIs: Sertaline 12.5mg, Citalopram 5 mg
○ Behavioral therapy ‒ Benzodiazepine- Clonazepam
• Approaches for preventing obesity: ‒ Hydroxyzine
○ Breastfeeding ‒ Gabapentine
○ Regular physical activity ○ Psychotherapy
○ Increasing physical activity in overweight people to prevent
the complications associated with obesity
○ Decreasing children’s time watching television
ANXIETY DISORDERS
• W Most common psychiatric disorders in the general population
V
• Onset in childhood, adolescence, or early adulthood
• More common in women than in men
• Anxiety
• May result from:
○ Drugs (caffeine, cannabis, cocaine, methamphetamine,
Iwithdrawal of alcohol or opiates
○ Medications( theophylline, steroids)
W
○ Medical conditions (e.g., asthma, arrhythmias,
2 temporal lobe epilepsy
• Primary Anxiety disorders
○ Excessive anxiety that interferes with daily functioning,
without apparent explanation or out of proportion to any
stressor
A A
○ Panic disorders, Generalized anxiety disorders, social anxiety
disorder, specific phobias
Fame bonde
Panic Disorder
I
• Sudden, intense attacks of fear of
• Recurrent, unexpected panic attacks, with at least one of the
I attacks followed - a
by a month or more of persistent concern about
having additional attacks or worry about their consequences (e.g., Social Anxiety Disorder (Social Phobia)
losing control, having a heart attack, going crazy) or a •A Anxiety in and avoidance of social situations - feels the center of
maladaptive change in behavior because of panic attacks (e.g.,
avoiding certain situations for fear of having an attack) ↑ I N
attention and fears humiliation, embarrassment, or being judged
negatively by other people
• Twice as common in women than in men • Symptoms:
a
• Risk factors:
○ Family history of panic disorder
○ Full blown panic attacks
A
~
‒ Public speaking of other public performances
○ Significant life stress in the year before the development of ‒ More pervasive form
f symptoms ‒ Avoidance to most social situations and
• Types: a
• Has genetic component (30% heritability) interactions
‒ Meeting new people, parties, initiating and
○ Situational panic attacks- Precipitated by frightening maintaining conversations, dating, group projects,
situations or heightened stress speaking with authority or asserting oneself
○ Spontaneous panic attacks- attacks without apparent
precipitant
Patron
• Complications: Falltime
**
○ Depression
○ Anticipatory anxiety (anxiety about having the next panic
attack)
○ Phobic avoidance
‒ Avoidance of situations in which the person has had or
would fear having a panic attack
○ Increased risk for suicide attempts
• Treatment
○ Reassurance
○ Education
|| || INSIGNIS 5
compulsive ritual (e.g., exposure to dirt without
the ability to wash one’s hands)
Post traumatic Stress Disorder (PTSD)

• Characteristic set of responses to a traumatic situation that
involves exposure to actual threatened death, serious injury, ore
sexual violence, either to oneself or experienced by witnessing
the trauma occurring to others, learning that the trauma has
happened to a close friend or family member, or working in a
setting with repeated or extreme trauma exposure
• acute stress disorder- Commonly experienced in the first month
Obsessive-compulsive Disorder following a major trauma
-
I
• PTSD- After a month, when most people would have recorded,
persistent symptom
• Risk factors:
○ Femal sex
-
○ Younger age
W
○- Severity and duration of the event
○-Lack of social support
○ -History of prior trauma
○
- History of preexisting psychiatric d/o
• Treatment: wow
○ Individual or group psychotherapy
GRAD
00c O
○ Medications: SSRIs, Valproate, Hypnotics, Prazosin
PSYCHOTROPIC MEDICATIONS and ORAL CONTRACEPTIVES

• Several psychotropic medications alter the metabolism and
efficacy oral contraceptive (OCS) or whose metabolism is in turn
altered by OCS
○ induction of the hepatic cytochrome P450 3A4 enzyme can
N
increase OCS metabolism and cause contraceptive failure
• o N
Persistent, repetitive thoughts, ideas or images that the patient • Medications associated with spotting, breakthrough bleeding or
O
finds irrational and intrusive (obsessions), with repetitive unwanted pregnancy:
O
behaviors or rituals (compulsions) designed to decrease the ○-Carbamazepine (tegretol)
-
anxiety caused by obsessions ○ Oxcabazepine (trileptal)
E
• Lifetime prevalence 2-3% ○ Topiramate (topamax; at doses above 200 mg daily)
a
• More common in monozygygotic than dizygotic twins ○ Modanil (provigil)
• ⑧-
Rates are similar in men and women - males have an earlier peak ○ St. John’s Wort
age of onset than females (6 to 15 years old vs. 20 to 29 years ○ Fluoxetine (prozac)
old) ○ Uvoxamine (luvox)
○ Males have higher comorbidity with Tourette’s syndrome • OCs can increase level and effects of the ff:
○ Conditions associated: ○ Amitriptyline (Elavil)
&
FromT
- ‒ Major depression ○ Brupropion (wellbutrin)
‒ Anxiety disorder ○ Chlordiazepoxide (libirum)
-
- ‒ Hypochondriacal concerns ○ Chlorpromazine (Orazine)
‒ Excessive use of alcohol and sedatives ○ Clozapine (Clorazil)
-
• Common obsessions: ○ Diazepam (Valium)
○ Fears of contamination, dirt, germs, and illness ○ Imipramine (Tofranil)
○ Doubts (e.g., about having locked the door, turned off the ○ Olanzapine (zyprexa)
oven, run over someone in one’s car) • OCs can lower blood levels of the ff:
○ Needing to have things in order ○ Nicotine
○ Sexual or religious images or preoccupations ○ Lamotigrine (Lamictal)
A• Compulsions:
N
○ Valproic acid (Depakote)
putting things in order I

○ Repetitive and excessive washing, cleaning, checking,
SUBSTANCE USE DISORDERS
•
O-
○ Asking for reassurance
Treatment: -
• Telescoping
○ accelerated progression of substance use disorder, with a
○ Medications: SSRIs, Clomipramine shorter time between first use of substance to onset of
○ Psychotherapy: dependence and then first treatment:
‒ Exposure and response prevention ‒ Alcohol
‒ Involves gradually increasing exposure to the
feared situation, without performing the S ‒ Cannabis
‒ Opiates
○ Reasons for telescoping:
|| || INSIGNIS 6
X
‒ Lower percentage of body water in women
‒ Lower levels of alcohol dehydrogenase in the gastric
• Screening tests that can help identify these disorders:
○ CAGE
V mucosa- decreased levels of first pass metabolism

‒ Slower rates of alcohol metabolism
‒ Brief and widely used screening test
‒ Helpful in detecting heavy drinking
○ T-ACE
Alcoholism
• Heavy drinking in women increases general health risks and is ‒ Variation of the CAGE
also associated with: ‒ Replaces the “guilt” about drinking item with a question
○ Amenorrhea about tolerance
○ Anovulation ‒ Used in pregnant women
○ Luteal phase dysfunction ‒ Recommended by ACOG
○ Early menopause ○ TWEAK
○ AUDIT
• Alcohol use during pregnancy is associated with fetal alcohol ‒ Well validated
syndrome and fetal alcohol effects, and most women avoid ‒ Included self-reports of quantity and frequency of drinking
alcohol once they know that they are pregnant.
• What is “safe” levels of alcohol use?

○ > 2 drinks per day on average is considered heavy drinking
for a woman (linked to increase in mortality, cirrhosis, and
breast cancer)
• Management:
○ Motivational interviewing
‒ Emphasizes reflective listening, rather than advice giving
‒ Physician express empathy and understanding of the
patients ambivalence and the obstacles to change,
avoids arguments, points out discrepancies between
the patients behavior and her goals, helps problem
solve ways to succeed in meeting goals, and supports
the patients own motivation and efforts to change
○ Pharmacologic : Naltrexone, Acamprosate, Topiramate
|| || INSIGNIS 7
Nicotine Dependence
-
• Increased risk for heart attacks, COPD, I
-
and lung cancer
a
• Associated with early menopause, spontaneousa abortion, LBW,
and preterm birth with in utero exposure
• Specific smoking cessation treatments:
I
○aNicotine patch
○ Bupropion
I
○ Varenicline rvr
Cannabis abuse
• Impaired memory, attention, and motivation
• Increases risk for the onset of panic attacks
• Increase vulnerability to depression and psychotic disorders
• Shorter gestation
• Decreased birth weight
• Possible impairments in executive functioning with in utero
exposure
• Treatment:
○ Cognitive behavioral therapy
○ Therapeutic communities
Heroin and other IV drug abuse
• Less frequently in women than in men
• More likely to inject drugs if their partner uses IV drugs and
introduces them to injection
Overuse of prescription narcotics:
• More common in women than in men
• Opiates and Methadone
○ Neonatal abstinence syndrome
○ Respiratory depression
○ Preterm delivery
○ Premature rupture of membranes
○ Fetal growth restriction
○ Meconium-stained amniotic fluid
DIFFICULT PATIENTS
• More likely to have a depressive or anxiety disorder, poor level
functioning, unmet expectations, low levels of satisfaction and
higher use of health care services
• Subset of patients who evoke negative feelings in many physician
• Misuse of habit forming prescribed medications or appear “drug
seeking”
• Challenge the physicians approach and not comply with
treatment recommendations
• “kindle aversion, fear, despair, or even downright malice in their
doctor
|| || INSIGNIS 8
|| INSIGNIS 9
Rape, Incest and Domestic Violence TWO – PHASES OF RAPE – TRAUMA SYNDROME:
HJ Fetalvero, MD, FPOGS

Al - IMMEDIATE OR ACUTE PHASE
ao Lasts from hours to days
o May be associated with paralysis of the individual’s
Source: Comprehensive Edition (20th Edition) + PPT
N usual coping mechanisms Whe
▪ Complete loss of emotional control to a well-
RAPE A
controlled behavior pattern
- Sexual assault of children, women and men and is a common act o Disorganized and may complain of:
- It is a legal term that refers to any penetration of a body orifice ▪ Physical Complaints (Soreness, Eating
-
with threat of force or actual force and nonconsent. Problems, Headaches, Sleep Disturbances)
- This type of crime, however, is often underreported, and the ▪ Behavioral Patters (Fear, Mood Swings,
- -
- -
actual incidence may be much higher. Anger, Difficulties in Concentrating,

Irritability, Guilt, Depression, Flashbacks of
- Victims are often reluctant to report sexual assault to the
the Attack)
authorities because of - REORGANIZATION PHASE
o 2 Embarrassment o Long term adjustment
o Fear of retribution F
o Flashbacks and nightmares may continue
I
o Feelings of guilt o Phobias may develop and may be directed against:
a
o Assumptions that little will be done ▪ Members of the Offending Sex
-
o Lack of knowledge of their rights.
Homeless women and women with mental illness are particularly S▪
▪
Sex act itself
Non-related circumstances (newly developed
fear of crowds or heights)
vulnerable to sexual assaults compared with the general o Lifestyle changes – jobs, residence, friends, and
population. significant others
- Sexual Violence is defined as any sexual act by one person on o Resolutions is more difficult:
another without that person’s consent ▪ Major complications occur – STDs and
o can be unwanted touching and rape, but it also includes Pregnancy
nonphysical distressing acts of sexual harassment, o PTSD
~
threats, peeping, and taking nude photos without
▪
v Disabling nightmares, flashbacks,
hyperarousal, avoidance, anxiety, and panic
consent ▪ Susceptible individuals:
• Prior History of Trauma before the
<
PHILIPPINE ANTI-RAPE LAW OF 1997 tr
rape
me
- Rape is committed by a man who shall have carnal knowledge of • Greater Severity, duration, and life-
the on
a woman under any of the following: threatening nature of the assault
a. Through force, threat or intimidation • Poor social support
b. When the offended party is deprived of reason or
otherwise unconscious
c. By means of fraudulent machination or grave use of
•
I Past history of depression or
anxiety
authority PHYSICIAN’S RESPONSIBILITY IN THE CARE OF A RAPE VICTIM

d. When the offended party is under 12 years of age or is
demented, even through none of the circumstances
mentioned above are present
~
SUSCEPTIBLE INDIVIDUALS
- Very Young
a
o
I
- Mentally and Physically Handicapped
I
- Very Old
- Homeless women
Most perpetrator are known to the victim and the assault is usually in a
familiar environment like the home
- First Rape Experience:
o - Intimate Partner (41.03%)
-
o Family Member (31.98%)
o Acquaintance (27%)
I g
-
W
VARIANTS
-
-
Marital Rape: forced coitus or related acts without consent but
within the marital relationship Wm
- Date Rape: woman may voluntarily participate in sexual play but MEDICAL RESPONSIBILITY
a
-
coitus is performed, often= forcibly, without her consent - A physician’s medical responsibility is to Treat Injuries and to
We
- Statutory Rape: criminalize coitus with females under certain perform appropriate tests for, to prevent, and to treat infections
specified ages, consent is irrelevant because the female is defined
-
- and pregnancies
by statute as being incapable of consenting o It is important to obtain informed consent before
I
o Under The Anti Rape Law of 1997 or RA no. 8353 – rape examining the patient and collecting specimens. In
is committed “when the offended party is under twelve addition to addressing legal requirements, it helps the
(12) years of age” 12 years old is same age cited as victim to regain control over her body and her life
statutory rape in Revised Penal Code in 1930
|| INSIGNIS Page | 1
--
o Determine acute injuries and stabilize the patient first, - Prophylactic Antibiotics – patient is concerned about contracting
a careful history and physical examination should be an STD or knows the assailant to be high risk
performed. It is important to have a chaperone present o CDC RECOMMENDATION:
0
while taking the history, performing the examination,
and collecting the specimen, to reassure the victim and A▪ 0
Ceftriaxone 250 mg IM (gonorrhea
to provide support. prophylaxis) +
o The presence of such a third party probably reduces ▪
~
Azithromycin 1g PO (chlamydia
A prophylaxis) +
feelings of vulnerability on the part of the victim. She
should be asked to state in her own words what ▪ Metronidazole 2g PO or Tinidazole 2g PO
happened; if she knew the attacker, and if not, to A (trichomonas prophylaxis)
describe the attacker; and to describe the specific act(s) a
performed.
- Om
If patient is Pregnant – NO medications and follow-up
-
screening
should be done in 2 weeks
o A history of previous gynecologic conditions, -
particularly infections and pregnancy, use of o If prophylaxis is desired, antibiotics given should be
contraception, and the date of last menstrual period, Class B
should be recorded. - If AT RISK for Pregnancy at the time of Assault – Emergency
o It is necessary to determine whether the patient may Contraception or “Morning After” prophylaxis can be given within
arum
have a preexisting pregnancy or be at risk for 120 hours after unprotected intercourse and offered as long as
pregnancy. the pregnancy test was negative
o It is also important to ascertain whether she has had a
↓ - PHYSICAL EXAMINATION:
-
preexisting pelvic infection
Lack of genital injury does not rule out assault. - ⑧
o Examination of the Perineum comes last
o Presence and State of the Hymen is noted – describe it
o Many injuries occur when the victim is restrained or
physically coerced into the sexual act. Seek for bruises, N --
-
--
using the Clock as reference e.g the laceration/abrasion
abrasions, or lacerations about the neck, back,
buttocks, or extremities. If a knife was used as a
O
is noted at 3 o’clock position
- The most important thing in medically examining someone who’s
coercive tactic, small cuts may also be found.
- -f
o Erythema, lacerations, and edema of the vulva or N been sexually assaulted is not to Re-rape the victim.
o Obtain consents, inform patient of every step
rectum may occur because of manipulation of these
areas with the hand or the penis. Common in children
-
o If the examiner is male have someone else preferably a
or-virginal victims but may occur in any woman and woman to observe
should be looked for. - A cardinal rule of medicine is ABOVE ALL DO NO HARM, rape
or
o Superficial or extensive lacerations N of the hymen,
posterior fourchette, or vagina may occur in virginal
victims or in the elderly.
victims often experience an intense feeling of helplessness and
loss of control
O
o Lacerations may also be noted in the area of the
-
MEDICOLEGAL RESPONSIBILITY
urethra, the rectum, and at times through the vaginal
- Medicolegal materials must be collected after the assault takes
vault into the abdominal cavity. Bite marks may be
place and definitely within 96 hours
noted in any of these regions.
- Victims should be encouraged to come immediately to a center
o Foreign objects are inserted into the vagina, the
where they can be evaluated before bathing, urinating,
urethra, or the rectum and may be found in situ.
defecating, washing out their mouths, changing clothes or
cleaning their fingernails
- Evidence for coitus will be present in the vagina for as long as 48
hours after the attack, but in other orifices the evidence may last
up to 6 hours
- History/PE – document the use of force, evidence for sexual
contact, and materials that may help identify the offender
(drawings or photographs)
- Rape and Sexual Assault are legal terms, they should not be
stated as diagnoses, the physician should report findings as
“Consistent with Use of Force”
- Sexual Contact – verified by analysis of secretions from the
vagina or rectum by identifying motile sperm
o In sone instance, motile sperm will be noted for as long
Common Routines done here: Sperm ID, Swabbing or Submission of Vaginal Discharge for as 3-5 days in the endocervix
Culture, HIV Testing o Nonmotile sperm may be present as well if the attack
occurred 12-20 hours previously
- Hepatitis B vaccine and HPV vaccine – if not previously

vaccinated
- Tetanus Prophylaxis – in some cases
- At follow up Visits → investigate for signs and symptoms of the
STDs (foul smelling discharges, pruritus, lesions and obtain
appropriate repeat cultures and serologies
- Aside for documenting that the intercourse has taken place, an FAMILY BACKGROUND
attempt should be made to identify the perpetrator
o All clothing intimately associated with the area of
-
N O
Families may appear normal – family members frequently have
- - -
- -
limited contact with the outside world

assault should be collected, labeled and submitted to - Family Relationships – oftenO chaotic, including problems such as
⑧
legal authorities adrug abuse
alcohol and -
and severe
-mental illness
o Smears of vaginal secretions or a Pap smear should be - Father-Daughter incestuous relationship – father is frequently a
made to permanently document the presence of sperm ~ passive, introspective person who experiences weak sexual
o Vaginal secretions needed for DNA typing should be relationship with the child’s mother
collected by wet or dry swab and refrigerated until a
pathologist can process them CHILD OUTCOME
O
No
- DNA Fingerprinting – no readily available in all areas and is - Feels guilty during adolescence
admissible in many jurisdictions - Afraid to withdraw from the relationship
-
o Pubic hair combings - Feel humiliated and develop poor self-esteem
o Saliva should be- collected from the victim to ascertain - May have difficulty in developing appropriate relationships with
- whether she secretes an antigen that could members of the opposite sex and may make poor choices in their
differentiate her from substances obtained from the interpersonal relationships in the future
perpetrator - Choose ⑧chaotic family existences after they leave home
o - Fingernail scrapings should be obtained for skin or - >10% of children have normal psychological development at the
blood if the victim scratched the perpetrator time of evaluation
o Specified blood or DNA typing may be conducted to - Majority has:
-help identify the attacker o a x
Guilt, anger, behavioral -
problems, unexplained physical
complaints
EMOTIONAL SUPPORT OF THE VICTIM o Lying, stealing, school Failure, Running Away, Sleep
- Discuss with the Victim Disturbances
o Degree of Injury
o Probability of Infection or Pregnancy ROLE OF GYNECOLOGISTS
o General course to follow and follow-up to aid - History taking should include – “Were you physically or sexually
prevention abused or raped as a child or adolescent?”
- Allow the victim to vent anxieties and correct misconceptions - Questioning should be nonjudgmental, clear, and specific
- Give reassurance that well-being will be restored - The patient should be questioned about the sexual activity
- Refer to individuals trained to help rape-trauma victims to experienced and whether it included touching, genital
facilitate counseling and follow-up manipulation or intercourse
- Release once specific follow-up plans were made
- Follow-up visits are planned within 1-4 weeks LONG-TERM EFFECT
o Reevaluate the patient’s medical, infectious disease, - Frequently choose partners capable of physical and sexual
pregnancy and psychological status violence
- Follow-up counseling
o Emphasize that she was a victim and holds no blame
A
- -
- a or
Difficulties in sexual adjustment: Promiscuity and Homosexuality
Married woman – had problem with sexual arousal and
demonstrated psychiatric symptoms of depression, anxiety and
FEMAL CIRCUMCISION I suicidal ideology
- A- form of sexual abuse only- recently observed
-
in the Western - Physical Effects:
-
--
world o Chronic Pelvic Pain
-
- Aa practice growing out of culturala I
and traditional beliefs dating o Chronic Fatigue Syndrome and Bladder Problems
back several thousand years
- WHO estimates that between-- 85 and 200 million women undergo DOMESTIC VIOLENCE
these procedures each year -- - Partner Abuse / Intimate Partner Violence (IPV) / Battered
- Removal
--
of the clitoris prepuce, Excision
-
of the clitoris Woman / Spouse Abuse
- -
- Removal of the Clitoris and labia minora - Violence occurring between partners in an ongoing relationship
>
o Some cases, labia majora is also partially removed and even if they are not married
K the vagina partially sutured closed - O
Battered Woman - any woman over the age of 16 with evidence
- Performed between early childhood and age 14 and frequently of physical abuse on at least one occasion at the hands of an
without anesthesia under unsterile conditions by untrained intimate male partner
practitioners - Battered Wife Syndrome - - symptom complex occurring as a
- Complications -
result of violence in which a woman has at any time received
I r A
o Infection, Tetanus, Shock, Hemorrhage, Death deliberate, severe or repeated (more than 3 times) physical abuse
- Long-term Problems from her husband or significant male partner in which the
N
o Chronic Infection, Scar Formation,oLocal Abscesses,
Sterility, Incontinence, Depression, Anxiety, Sexual -
minimal is bruising
PATTERN OF COERCIVE BEHAVIORS
O
Dysfunction, Obstetric Complications o-Repeated Battering and Injury
INCEST o-Psychological or Emotional Abuse
of
2 types:
-
-
Child is victimized by a stranger
Family Member orO Friend is the Perpetrator
o-Sexual Assault
o-Progressive Societal Isolation
o Economic Deprivation
*Brother-sister incest may be the most common from but may not be oo Intimidation and Stalking
reported often - May vary from minimal activity, such as verbal abuse or threat of
violence to throwing an object at someone, pushing, slapping,
kicking, hitting, beating, threatening with a weapon or using a
weapon
- COMMON SITES OF INJURY
8/
o Head, neck, chest, abdomen, breast,rupperr
X & extremities
o
abuse
00
Attack may take the form of both verbal and physical
- EFFECTS OF IPV
o Murder, Suicide, Kill thea
/ Batterer
o
OVictim is often left injured
▪ In self-defense, the victim may actually injure
- Prenatal Child Abuse - Physical abuse in Pregnancy with an or kill the batterer
O
incidence rate of 1-20%
- THIRD PHASE OF BATTERING
RECOGNITION OF DOMESTIC VIOLENCE Ve
o After the abuse has taken place, these phases generally
r
- Characteristics of the Abused Wife:
A
follow. Batterer apologizes, ask forgiveness and
0
y
o N History of having been beaten as a child frequently shows kindness and remorse, showering the
o Raised in a O
N
o Married as aO
single-parent home
teenager
victim with gifts and promises
o Gives them⑧ hope that the relationship can be saved and
o A Pregnant before a marriage that the violence will not recur
- Frequent visit -clinics and emergency
-
rooms with a variety of o Batterers – charming and manipulative, offering the
somatic complains victim justification for forgiveness
o Cycles repeat themselves
▪ First phase increasing in length and intensity
▪ Battering becoming more severe
▪ Third phase tending to decrease in both
duration and intensity
o Batterer learns that he can control the victim without
obtaining much forgiveness
o Victim becomes more demoralized and loses her ability
to leave the situation even if she has the means and
opportunity to do so
PROFILE OF BATTERERS
- Refuse to take responsibility for their behavior, blaming their
victims for their violent acts
- Often have strong controlling personalities and do not tolerate
autonomy in their partners
- Have a rigid expectation of marriage and sexual behavior and
ROLE OF PHYSICIANS: consider their wives or partners as chattel
-
rComfortable in asking the patient whether she has been
physically abused
- Wish to be cared in their most basic needs, frequently make
unrealistic demands on their wives and show low tolerance for
-
-
OScreen every pregnant woman for intimate partner violence
Ask questions such as: (Appropriate introductory questions) -
stress
Depression and suicide attempt often a part of their behavior
->
↑
o “Has anyone hurt you or tried to injure you?”
o “Has an intimate partner ever threatened you with -
pattern
Aggressive and assaultive in most of their behavior, generally
- violence?”
physical using violence to solve their problems
o “Have you ever been physically abused either recently - Often charming and manipulative, especially in their relationships
or8in the past?” outside the marriage
- OPhysician should follow up on any - positive answers in a - Exhibit low self-esteem, feelings of inadequacy and a sense of
nonjudgmental manner in an attempt to learn what is happening helplessness, all of which are generally made worse by the
- OPE: Complete particular attention to: prospects of losing their wives
o Bruises, Burns, Improbably Injury and other signs of - Exhibit contempt for women in their usual activities
injury - Therapy: usually ineffective and seems to work only when the
- If the patient is pregnant – bruises seen on the breasts or man can be made to give up violence as his primary means of
abdomen should always be discussed solving problems
- Carefully note evidence for abuse in the patient’s record
ROLE OF PHYSICIANS
PHASES OF BATTERING - Attend to the patient’s injuries
- TENSION BUILDING - Assess the patient’s emotional status from the standpoint of a
o Tension in couple escalates psychiatric condition such as a suicidal ideation, depression,
o Name calling, intimidating remarks, meanness, and anxiety or signs of abuse of drugs, alcohol or other medications
mild physical abuse such as pushing - Estimate the woman’s ability to assess her own situation and
o Batterer often expresses dissatisfaction and hostility in readiness to take appropriate action
a somewhat chronic form o Recognize the problem and either offer counseling or
o Victim may attempt to placate the batterer in hopes of get counseling for the patient so that she understands
pleasing him or calming him her rights and alternatives and learns to protect herself
o As the tension phase builds, the batterer’s anger is less and her children from harm
controlled and the victim may withdraw, fearing that o Problems involving mental illness – referral to an
she will inadvertently set off explosive behavior appropriate mental health worker who is sensitive to
the issues of domestic violence
- ACUTE BATTERING o Determine community resources available for handling
o Uncontrollable discharge of tension that has built up family violence
through the first phase
ROLE OF HEALTHCARE WORKERS
- Social workers, psychologists, psychiatrist or other mental health
workers trained specifically for this purpose
o Offer counseling and follow-up care
- Police department, crisis hotline, rape relief center, domestic
violence programs and legal aid services for abused women
o Offer help in the acute situation
THE VICTIM
I
-
O-
Very likely will not wish to leave her home because of economic
concerns and a fear that the batterer may continue to pursue her
o Although she may have the batterer arrested and
served with restraining orders, she may be convinced
that she and her children cannot be protected from the
batterer
- Believe that these is a possibility of reconciliation and of change
in behavior on the part of the batterer
- It is therefore reasonable to discuss an exit plan with the victim
to be used should the violence recur
EXIT PLAN
- Have a change of clothes packed for both her and her children
including toilet article, necessary medications and an extra set of
⑧
keys to the house and care. These can be placed in a suitcase and
left with a friend or family member
-
00 c
Keep some cash, a checkbook and savings account book with a
⑤
friend or family member
- -
Other identification papers such as birth certificates, social
O a
security cards, voter registration cards, utility bills and driver’s
license, should be kept available because children will need to be
enrolled in school and the woman may have to seek financial
assistance
-
-
⑧
Have something special such as a toy or book for each child
Have financial records available such as mortgage papers, rent
receipts and automobile title
- - Determine a plan on exactly where to go regardless of the time
of day or night
- Ask neighbors to call police if violence begins
- Remove weapons
- Teach children to call 911/ emergency
OUTCOME
- Severe Psychiatric Problems
o Anxiety
o Depression
o PTSD
o Other pathologic conditions that may require
psychotherapy
SERVICES
- Group counseling or individual counseling
- Skills development

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Gynecology Amenorrhea

AY 2021-2022 Renna Cristina B. de Leon, MD, FPOGS, FIFEPAG

OUTLINE II. Puberty

▪ Onset of puberty and menarche is determined by the body

▪ Studies have noted that those living in higher altitudes

sml Excelsus 2023 1 of 9

(sorry couldn’t find a clearer picture)

Breast Tanner Staging

● Cryptomenorrhea is caused by anatomic disorders interfering

● WHO Classification of Women (outside the US)

● What we use, based on anatomy

Type I – Breasts Absent and Uterus Present

A. Gonadal Failure (Hypergonadotropic Hypogonadism)

▪ Work up in Turner’s Syndrome:

− Decreased cortisol  elevated ACTH

growth velocity < 2 cm/year Central Nervous System Lesions

o Progestins (5 – 10 mg medroxyprogesterone → HYPOTHALAMIC FAILURE

prevent endometrial hyperplasia

− Prepubertal hypothyroidism → Renal abnormalities

− Kernicterus → Cardiac abnormalities

breast development and epiphyseal closure) out a lesion

malignant potential vOw

▪ Very low E2 levels (below)

▪ Low E2, Low FSH

→ Non-prolactin secreting pituitary tumors

q ▪ Advise to gain weight

Family Planning modern methods (mCPR) among

LEARNING OUTCOMES Table 13.3 WHO Summary Table of Contraceptive Efficacy

CURRENT CONTRACEPTIVE STATUS

 Sterilization - most common contraception used in the

1. COPPER T 380A IUD duration of use of the device

of gonorrhea and chlamydia should be

3|I nsi gni s

4|I nsi gni s

individual woman’s response

o Combined oral contraceptives (COCs)  Contraindications to Oral Contraceptive Use

7|I nsi gni s

 Currently, most dedicated EC medications contain the

8|I nsi gni s

- Metabolic influences and GnRH release

Functional Reproductive System

• Growing evidence indicates that complex and

* Everything is interconnected. Not one organ functions alone.

Hypothalamus and GnRH Leptin

Inhibitory * Gamma amino-butyric acid (GABA)

* Corticotropin-releasing hormone (CRH) ↓

Stimulate follicular growth Stimulate ovarianO

• Following adm of these agonists Initial stimulation of

* Primary/Preantral Follicle – development is relatively

* Primary/Preantral Follicle – development is relatively

One primary function of the ovary is the secretion of ovarian

Three primary ovarian hormones

Other hormones secreted by the ovary:

* Ovarian hormones are steroid hormones.

• Binds dihydrotestosterone, testosterone and Inhibin

secretion (from developing

*These processes occur in sequence, conferring in monthly

Selection of Dominant Follicle OVULATORY GONADOTROPIN SURGE AND OVULATION

follicular phase • LH levels increase 10-fold over a period of 2 to 3 days &

concentration insufficient to sustain growth in the other