Wed. Jul 24th, 2024

Endometriosis is the abnormal location of endometrial tissue that can occur within the myometrium or at external sites such as the outer surface of the uterus, Fallopian tubes, ovaries, bladder, appendix or bowel. This aberrant tissue responds to ovarian hormones as normal endometrial tissue would thus causing the site dependent symptoms. The most common symptom is low abdominal or pelvic pain associated with onset of menstruation. Pain during sexual intercourse indicates uterine involvement and pain during urination reflects bladder involvement. No laboratory test is available. Physical examination and exploratory surgery may be necessary to identify the lesion. Symptoms are generally handled with analgesics in women of childbearing years where the symptoms are not severe. Hormone therapy that prevents ovulation may be helpful. When the endometriosis is embedded within the myometrium, hysterectomy is indicated to prevent the symptoms of painful intercourse, severe cramps and pelvic discomfort.

Premenstrual Syndrome (PMS)
PMS is the name given to the common symptoms that accompany the onset of the monthly period. Symptoms include headache, mood changes, breast tenderness, bloating, edema, weight gain, backache, irritability, depression, and anxiety. Treatment is symptomatic and includes analgesics, diuretics, tranquilizers and sedatives.

More commonly referred to as cramps, dysmenorrhea is painful menstruation caused by abnormal uterine contractility that effects some 50% of menstruating women. Primary dysmenorrhea is that which is not related to an obvious physical cause. Sharp cramps are experienced the first couple days of the menses. Headache, nausea, vomiting, diarrhea and fatigue also may be symptoms of dysmenorrhea and are thought to be caused by the liberation of prostaglandins in the endometrium. Treatments include analgesics, antiprostaglandins and hormones. Non-steroidal anti-inflammatory drugs, such as aspirin, indomethacin, and ibuprofen inhibit prostaglandin synthesis and act as analgesics. In severe cases, hormone therapy is initiated to prevent ovulation as anovulatory cycles are usually painless.

Dysmenorrheic women produce more prostaglandins in the endometrium and menstrual fluids than those without dysmenorrhea. Dysmenorrheic women also have been reported to have lower progesterone levels than normal women creating a dominance of estrogen in the endometrium which favors prostaglandin synthesis. At the end of an ovulatory cycle progesterone declines leading to a cascade of enzymatic events that lead to the production of prostaglandins. These prostaglandins cause uterine hypercontractility, decreased blood flow and ischemia, and uterine hypoxia that causes pain. Cyclooxygenase inhibitors such as aspirin, naproxen or ibuprofen prevent the formation of prostaglandins and relieve the symptoms of dysmenorrhea. Oral contraceptives inhibit ovulation (prevent formation of corpus luteum and decrease the thickness of the endometrial lining) and therefore prevent the environment necessary for increased prostaglandin production.

Physiologic amenorrhea, or the cessation of menstrual periods, normally occurs in pregnancy, lactation, adolescence, and menopause. Pathologic amenorrhea may be caused by endocrine disorders such as dysfunction of the hypothalamus, pituitary, ovary, thyroid or adrenal glands. Metabolic and psychogenic causes include malnutriton, obesity, chronic stress, drug addiction, diabetes, anorexia nervosa and anemia. Removal of the underlying cause will usually result in the resumption of normal periods. If hormone deficiencies are found, substitutional therapy is recommended.

Primary amenorrhea is hypogonadotropic and hypogonadal, meaning that blood levels of the gonadotropins and gonadal steroids are abnormally low. Release of LH and FSH are inhibited by endorphins at the level of the hypothalamus where they inhibit GnRH release. Without the gonadotropins the ovaries do not make gonadal steroids. Stress of many difererent kinds causes the synthesis of an ACTH precursor molecule in the hypothalamus that contains the sequence for endorphin and enkephalin. The cells making and processing the precursor are in direct contact with cells that make GnRH.

A shift in body composition or weight loss as in anorexia nervosa, ballet dancers, long-distance runners or malnutrition can cause amenorrhea. There seems to be a body fat threshold for the maintenance of normal cycles that is in the neighborhood of 18%. In many of these cases, if the patient gains weight normal cycles will resume. In obesity, weight loss and the concomitant decrease in stress on the body will enable a resumption of normal function. Amenorrhea may also result from psychogenic causes such as depression or chronic emotional stress.

The female reproductive tract is subject to bacterial, fungal, protozoal and viral infections. Many of these, such as trichomonas, gonorrhea, genital herpes and syphilis affect the vagina and external genitalia. Those that are sexually transmitted are covered at Infections of the upper reproductive tract (above the cervix) are lumped together under the heading of pelvic inflammatory disease. Common causes of pelvic inflammatory disease include Gonococcus, Staphylococcus, Streptococcus and Chlamydia. It is associated with IUD use, abortion and post delivery. Symptoms include severe pelvic pain, chills, fever, nausea, vomiting, and a heavy odorous vaginal discharge. Treatment depends on the cause and extent of the infection but may include hospitalization, antibiotics, and analgesics. Inadequately treated pelvic inflammatory disease may result in infertility or sterility.