Menstrual Menstrual dysfunctiondysfunction

Functional components of Functional components of menstruationmenstruation

hypothalamus, hypothalamus, pituitary, pituitary, ovary, ovary, outflow tract,outflow tract, feedback mechanismfeedback mechanism

Primary amenorrheaPrimary amenorrhea is defined as the is defined as the absence of menses by 16 years of age absence of menses by 16 years of age in the presence of normal secondary in the presence of normal secondary sexual characteristics, or by 14 years sexual characteristics, or by 14 years of age when there is no visible of age when there is no visible secondary sexual characteristic secondary sexual characteristic development.development.

Secondary amenorrheaSecondary amenorrhea - absence of - absence of menses for 6 months in a previously menses for 6 months in a previously menstruating femalemenstruating female

AmenorrheaAmenorrhea1. Genuine & false1. Genuine & false

2. Primary & secondary2. Primary & secondary

3. Physiological & pathological3. Physiological & pathological

4. The hypothalamic amenorrhea, 4. The hypothalamic amenorrhea,

The pituitary amenorrhea,The pituitary amenorrhea,

The ovarian amenorrhea,The ovarian amenorrhea,

The uterine form of amenorrhea.The uterine form of amenorrhea.

The hypothalamic The hypothalamic amenorrheaamenorrhea

Psychogenic amenorrheaPsychogenic amenorrhea Amenorrhea during falls pregnancyAmenorrhea during falls pregnancy Amenorrhea as a symptom of nervous anorexiaAmenorrhea as a symptom of nervous anorexia Amenorrhea as a symptomAmenorrhea as a symptom of adiposogenital of adiposogenital

dystrophydystrophy Amenorrhea as a symptom of the Lorence-Amenorrhea as a symptom of the Lorence-

Moon-Barde-Bidle syndromeMoon-Barde-Bidle syndrome Amenorrhea as a symptom of the Amenorrhea as a symptom of the

Morghani_Stuart syndromeMorghani_Stuart syndrome Amenorrhea as a symptom of the persistent Amenorrhea as a symptom of the persistent

lactation syndrome (the Kiari-Fromel syndrome)lactation syndrome (the Kiari-Fromel syndrome)

Psychogenic Psychogenic amenorrhea amenorrhea

Appears as a result of stress situation Appears as a result of stress situation or psychic traumasor psychic traumas

Excessive production of corticotropin Excessive production of corticotropin within stress blocs production of within stress blocs production of releasing hormones by Hypotalamus.releasing hormones by Hypotalamus.

Treatment:Treatment:– psychotherapy, psychotherapy, – sedative remedies, sedative remedies, – physiotherapy. physiotherapy. – After 2-3 months of treatment without After 2-3 months of treatment without

result we prescribe thyroidin.result we prescribe thyroidin.

Amenorrhea during Amenorrhea during falls pregnancyfalls pregnancy

Appears in women, who are eager or very Appears in women, who are eager or very afraid to become pregnant.afraid to become pregnant.

Clinical features:Clinical features:– NauseaNausea– Morning vomitingMorning vomiting– Swelling of breastSwelling of breast– Some enlarging & softening of uterus can Some enlarging & softening of uterus can

appearappear

But all test for pregnancy are But all test for pregnancy are negative. negative.

Rule out pregnancy!Rule out pregnancy!

Anorexia NervosaAnorexia Nervosa Onset between ages 10 and Onset between ages 10 and

30.30. Weight loss of 25% or weight Weight loss of 25% or weight

15% below normal for age and 15% below normal for age and height.height.

Special attitudes:Special attitudes: ——Denial,Denial, ——Distorted body image,Distorted body image, ——Unusual hoarding or handling Unusual hoarding or handling

of food.of food.At least one of the following:At least one of the following: ——Lanugo,Lanugo, ——Bradycardia,Bradycardia, ——Overactivity,Overactivity, ——Episodes of overeating Episodes of overeating

(bulimia),(bulimia), ——Vomiting, which may be self-Vomiting, which may be self-

induced.induced.

Amenorrhea.Amenorrhea. No known medical No known medical

illness.illness. No other psychiatric No other psychiatric

disorder.disorder. Other characteristics:Other characteristics: ——Constipation,Constipation, ——Low blood pressure,Low blood pressure, ——Hypercarotenemia,Hypercarotenemia, ——Diabetes insipidus.Diabetes insipidus.

Cessation of Cessation of menstrual cycle via menstrual cycle via endurance endurance activities, activities, inadequate body inadequate body weight, eating weight, eating disorder, stressdisorder, stress

Reestablish normal Reestablish normal hormone levels via hormone levels via diet and exercise diet and exercise counseling, counseling, hormone therapyhormone therapy

Anorexia Anorexia NervosaNervosa

Female Athlete Female Athlete TriadTriad

Eating disorder/disordered eating

Amenorrhea Osteoporosis

Amenorrhea as a symptomAmenorrhea as a symptom of of adiposogenital dystrophyadiposogenital dystrophy

It is usually associated with It is usually associated with tumours of the of the hypothalamus, causing increased appetite and hypothalamus, causing increased appetite and depressed secretion of gonadotropin. It seems to depressed secretion of gonadotropin. It seems to affect males mostly.affect males mostly.

Is a condition characterized byIs a condition characterized by Feminine obesity Feminine obesity Growth retardation and retarded sexual Growth retardation and retarded sexual

development, atrophy or hypoplasia of the development, atrophy or hypoplasia of the gonads, and altered secondary sex gonads, and altered secondary sex characteristics, characteristics,

headaches headaches mental retardation, problems with vision mental retardation, problems with vision polyuria, polydipsia. polyuria, polydipsia.

Diagrammatic representation of empty sella syndrome. A, Normal anatomic relationship. B, C, and D, Progression in development of empty sella syndrome. Note thinning of floor and symmetric enlargement of sella turcica.

tumours of the tumours of the hypothalamushypothalamus

Amenorrhea as a symptom of the Amenorrhea as a symptom of the Laurence-Moon-Barde-Bidle Laurence-Moon-Barde-Bidle

syndromesyndromeLaurence-MoonLaurence-Moon syndrome comprises syndrome comprises Onset in childhood. Onset in childhood. Inheritance is autosomal recessive.Inheritance is autosomal recessive. retinitis pigmentosa, initially, problem of night vision; retinitis pigmentosa, initially, problem of night vision;

then central vision and then peripheral vision loss then central vision and then peripheral vision loss progressing to blindness. progressing to blindness.

mental retardation, mental retardation, stunted stature stunted stature hypogonadism. hypogonadism. Spinocerebellar ataxia and progressive spastic Spinocerebellar ataxia and progressive spastic

paraplegia paraplegia The complete syndrome is seldom observed in the The complete syndrome is seldom observed in the

same individual, but the features are often scattered same individual, but the features are often scattered among the siblings of one family or generation. among the siblings of one family or generation. Members of these families have an increased number Members of these families have an increased number of miscarriages and early deaths.of miscarriages and early deaths.

Amenorrhea as a symptom of Amenorrhea as a symptom of the Morghani-Stuart syndromethe Morghani-Stuart syndrome

The main features of this hereditary The main features of this hereditary syndrome are: syndrome are:

1) hyperostosis frontalis interna, 1) hyperostosis frontalis interna, 2) adipositas, 2) adipositas, 3) virilism and hirsutism3) virilism and hirsutism 4) menstrual disorders4) menstrual disorders

Treatment is symptomaticTreatment is symptomatic

Hyperprolactinemia has Hyperprolactinemia has such causes:such causes:

-prolactin-secreting pituitary adenomas-prolactin-secreting pituitary adenomas -other pituitary or hypothalamic tumors that may distort the -other pituitary or hypothalamic tumors that may distort the

portal circulation and thereby prevent effective delivery of portal circulation and thereby prevent effective delivery of hypothalamic dopamine (the putative prolactin inhibitory hypothalamic dopamine (the putative prolactin inhibitory factor or hormone)factor or hormone)

-a variety of drugs that lower dopamine levels or inhibit -a variety of drugs that lower dopamine levels or inhibit dopamine action (amphetamines, benzodiazepines, dopamine action (amphetamines, benzodiazepines, butyrophenones, metoclopramide, methyldopa, opiates, butyrophenones, metoclopramide, methyldopa, opiates, phenothiazines, reserpine, and tricyclic antidepressants)phenothiazines, reserpine, and tricyclic antidepressants)

-breast or chest wall surgery, cervical spine lesions, or -breast or chest wall surgery, cervical spine lesions, or herpes zoster (activation of the afferent sensory neural herpes zoster (activation of the afferent sensory neural pathway that stimulates prolactin secretion, in a manner pathway that stimulates prolactin secretion, in a manner similar to suckling)similar to suckling)

-hypothyroidism (increased hypothalamic thyrotropin--hypothyroidism (increased hypothalamic thyrotropin-releasing hormone stimulates pituitary prolactin secretion releasing hormone stimulates pituitary prolactin secretion directly)directly)

-pharmacologic estrogens (OCP)-pharmacologic estrogens (OCP) -other rare, nonpituitary sources (lung and renal tumors) or -other rare, nonpituitary sources (lung and renal tumors) or

causes of decreased prolactin clearance (renal failure).causes of decreased prolactin clearance (renal failure).

The pituitary The pituitary amenorrheaamenorrhea

Amenorrhea as a symptom of pituitary Amenorrhea as a symptom of pituitary nanismnanism

Amenorrhea as a symptom of gigantism Amenorrhea as a symptom of gigantism and acromegaliaand acromegalia

Amenorrhea as a symptom of Itsenco-Amenorrhea as a symptom of Itsenco-Kushing’s diseaseKushing’s disease

Amenorrhea as a symptom of Shichane Amenorrhea as a symptom of Shichane diseasdiseas

Amenorrhea in case of Amenorrhea in case of pituitary nanismpituitary nanism

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

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

Amenorrhea in case of Amenorrhea in case of gigantism and gigantism and acromegaliaacromegalia

Diseases are caused by Somatotropin Diseases are caused by Somatotropin hyperprodaction, production of hyperprodaction, production of gonadothropic hormones is decreased. gonadothropic hormones is decreased. Amenorrhea has a secondary character.Amenorrhea has a secondary character.

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

Itsenko-Cushing Itsenko-Cushing syndromesyndrome

Clinical features areClinical features are:: fatigue, fatigue, weakness, weakness, abdominal obesity, abdominal obesity, «buffalo hump» (an excessive deposit of fat «buffalo hump» (an excessive deposit of fat

over the clavicles and back of the neck), over the clavicles and back of the neck), moon-shaped face, moon-shaped face, nervousness, nervousness, irritability, irritability, depression, depression, amenorrhoea or menstrual irregularity. amenorrhoea or menstrual irregularity. Most commonly observed in females in Most commonly observed in females in

childbearing age. childbearing age.

Hirsutism, plethora, abdominal striae, Hirsutism, plethora, abdominal striae, diabetes mellitus, osteoporosis, diabetes mellitus, osteoporosis, increased susceptibility to infection, increased susceptibility to infection, cataracts, renal calculi, senile purpura, cataracts, renal calculi, senile purpura, proximal myopathy, hypertension may proximal myopathy, hypertension may be associated. be associated.

The syndrome may be recognized soon The syndrome may be recognized soon after birth; children with it have stunted after birth; children with it have stunted growth. growth.

It can also be caused by treatment with It can also be caused by treatment with corticosteroids.corticosteroids.

Itsenko-Cushing Itsenko-Cushing syndromesyndrome

““Moon face”Moon face”

Plethoricface

(NO HIRSUTISM)Supra-clavicularfat pads

Sheehan's SyndromeSheehan's Syndrome Acute infarction and necrosis of the pituitary Acute infarction and necrosis of the pituitary

gland due to postpartum hemorrhage and shock gland due to postpartum hemorrhage and shock is known as Sheehan's syndrome. is known as Sheehan's syndrome.

The symptoms of hypopituitarism are usually The symptoms of hypopituitarism are usually seen early in the postpartum period, especially seen early in the postpartum period, especially failure of lactation and loss of pubic and axillary failure of lactation and loss of pubic and axillary hair. hair.

Deficiencies in growth hormone and Deficiencies in growth hormone and gonadotropins are most common, followed by gonadotropins are most common, followed by ACTH, and last, by TSH in frequency. Diabetes ACTH, and last, by TSH in frequency. Diabetes insipidus is not usually present. This can be a life-insipidus is not usually present. This can be a life-threatening condition, but fortunately, because of threatening condition, but fortunately, because of good obstetrical care, this syndrome is never good obstetrical care, this syndrome is never encountered by most of us.encountered by most of us.

The ovarian The ovarian amenorrheaamenorrhea

The Shereshevsky-Terner’s The Shereshevsky-Terner’s syndromesyndrome

The Stein-Levental syndromeThe Stein-Levental syndrome

What is Turner What is Turner syndrome?syndrome?

Relatively common Relatively common disorder caused by disorder caused by the loss of genetic the loss of genetic material from one of material from one of the sex the sex chromosomes. chromosomes.

Affects only femalesAffects only females

Genetic causesGenetic causes X X

chromosome chromosome monosomymonosomy

X X chromosome chromosome mosaicismmosaicism

X X chromosome chromosome defectsdefects

SymptomsSymptoms

Clinical Clinical featuresfeatures

Short stature (143-145cm tall)Short stature (143-145cm tall) Loss of ovarian functionLoss of ovarian function Hormone imbalances( thyroid, Hormone imbalances( thyroid,

diabetes) diabetes) Stress and emotional deprivationStress and emotional deprivation Diseases affecting the kidneys, heart, Diseases affecting the kidneys, heart,

lungs or intestineslungs or intestines Bone diseases Bone diseases Learning problems( esp. in maths)Learning problems( esp. in maths)

Gonadal failureGonadal failure

Internal genitalia of patient with gonadal dysgenesis (Turner syndrome), featuring normal but infantile uterus, normal fallopian tubes, and pale, glistening "streak" gonads in both broad ligaments.

DiagnosisDiagnosis Possible during Possible during

infancy or early infancy or early childhood childhood

A physical exam is A physical exam is the first indicationthe first indication

The best test is a The best test is a karyotype, ie a karyotype, ie a laboratory test laboratory test presenting the presenting the chromosomes chromosomes

TreatmentTreatment Growth hormone therapyGrowth hormone therapy Estrogen replacement therapyEstrogen replacement therapy Cardiac surgery (when needed)Cardiac surgery (when needed) In vitro fertilization (to achieve pregnancy)In vitro fertilization (to achieve pregnancy) Psychological helpPsychological help

Polycystic Ovarian Polycystic Ovarian SyndromeSyndrome

Sagittal section of a polycystic ovary illustratinglarge number of follicular cysts and thickened stroma.

PathologyPathology an inversion of the normal an inversion of the normal

LH/FSH ratioLH/FSH ratio lack of ovulationlack of ovulation increased levels of male increased levels of male

hormones ("androgens")hormones ("androgens") insulin resistanceinsulin resistance

PresentationPresentation irregular or absent irregular or absent

menstruation/ovulationmenstruation/ovulation infertilityinfertility undesired hair growth and acne undesired hair growth and acne small benign cysts on the ovaries small benign cysts on the ovaries increasedincreased  risk of miscarriagerisk of miscarriage obesityobesity endometrial cancer, heart disease endometrial cancer, heart disease

and diabetesand diabetes

DiagnosisDiagnosis BBT (basal body temperature) BBT (basal body temperature) B ultrasound:B ultrasound:

multiple small ovarian cysts multiple small ovarian cysts

enlarged ovaryenlarged ovary Endometrium biopsy(Curettage )Endometrium biopsy(Curettage )

before menses reveal to proliferative glandsbefore menses reveal to proliferative glands Determination of LH,FSH,E2,P,T,PRLDetermination of LH,FSH,E2,P,T,PRL ，， InsIns ，，

(LH:FSH≧3:1)(LH:FSH≧3:1) LaparoscopyLaparoscopy

TreatmentTreatment If pregnancy is desired - cause If pregnancy is desired - cause

ovulation ovulation anti-strogens(clomiphene)anti-strogens(clomiphene) GonadotropinsGonadotropins insulin-lowering agentsinsulin-lowering agents anti-androgens (agents that lower anti-androgens (agents that lower androgen levels)androgen levels) gonadotropin releasing hormone gonadotropin releasing hormone agonists (GnRHa)agonists (GnRHa)

If pregnancy is not desiredIf pregnancy is not desired

to reduce the risk of endometrial to reduce the risk of endometrial cancer( birth control pills)cancer( birth control pills)

cyclical progesteronecyclical progesterone (MPA, Provera) (MPA, Provera)

insulin-lowering agentsinsulin-lowering agents (metformin ,Glucophage)(metformin ,Glucophage)

anti-androgens.anti-androgens.

The uterine form of The uterine form of amenorrheaamenorrhea

PrimaryPrimary– Uterus congenital anomaliesUterus congenital anomalies

SecondarySecondary– Postinflammation intrauterine Postinflammation intrauterine

synechyassynechyas– Endometrium traumaEndometrium trauma– Tuberculosis of endometriumTuberculosis of endometrium

Imperforate HymenImperforate Hymen

Mayer-Rokitansky-Kuster-Hauser Mayer-Rokitansky-Kuster-Hauser Syndrome (utero-vaginal agenesis)Syndrome (utero-vaginal agenesis)

15% of primary 15% of primary amenorrhea amenorrhea

Normal secondary Normal secondary development & external development & external female genitaliafemale genitalia

Normal female range Normal female range testosterone leveltestosterone level

Absent uterus and upper Absent uterus and upper vagina & normal ovariesvagina & normal ovaries

Karyotype 46-XXKaryotype 46-XX 15-30% renal, skeletal and 15-30% renal, skeletal and

middle ear anomaliesmiddle ear anomalies

X-ray film of patient with Asherman syndrome. Patient (33 X-ray film of patient with Asherman syndrome. Patient (33 years, gravida 3, para O, abortus 3) had been amenorrheic for years, gravida 3, para O, abortus 3) had been amenorrheic for 6 months after D&C for most recent therapeutic abortion 6 months after D&C for most recent therapeutic abortion (TAB). Filling of endocervical canal and nonvisualization of (TAB). Filling of endocervical canal and nonvisualization of endometrial cavity are consistent with complete obliteration endometrial cavity are consistent with complete obliteration of cavity by adhesions or with obstruction at internal os level of cavity by adhesions or with obstruction at internal os level by adhesions in lower endometrial cavity. This appearance by adhesions in lower endometrial cavity. This appearance may also be seen with advanced endometrial tuberculosis.may also be seen with advanced endometrial tuberculosis.

Asherman syndrome

COMPLICATIONS OF COMPLICATIONS OF MENSTRUATION MENSTRUATION

Premenstrual Premenstrual syndromesyndrome

Symptoms include edema, weight gain, Symptoms include edema, weight gain, restlessness, irritability, and increased restlessness, irritability, and increased tension.tension.

Symptoms must occur in the second Symptoms must occur in the second half of the menstrual cycle.half of the menstrual cycle.

There must be a symptom-free period There must be a symptom-free period of at least 7 days in the first half of the of at least 7 days in the first half of the cycle.cycle.

Symptoms must occur in at least 2 Symptoms must occur in at least 2 consecutive cycles.consecutive cycles.

Symptoms must be severe enough to Symptoms must be severe enough to require medical advice or treatment.require medical advice or treatment.

MastodyniaMastodynia Pain, and usually swelling, of the breasts caused by Pain, and usually swelling, of the breasts caused by

edema and engorgement of the vascular and edema and engorgement of the vascular and ductal systems is termed mastodynia, or mastalgia.ductal systems is termed mastodynia, or mastalgia.

TreatmentTreatment Management of painful breasts due to fibrocystic Management of painful breasts due to fibrocystic

changes consists of support of the breasts, changes consists of support of the breasts, avoidance of methylxanthenes (coffee, tea, avoidance of methylxanthenes (coffee, tea, chocolate, cola drinks), and occasional use of a chocolate, cola drinks), and occasional use of a mild diuretic. mild diuretic.

Patients with mastodynia have had improvement Patients with mastodynia have had improvement with danazol, bromocriptine, oral contraceptives, with danazol, bromocriptine, oral contraceptives, and vitamins, though with limited success. Iand vitamins, though with limited success. I

In one study, lisuride maleate, a dopamine agonist, In one study, lisuride maleate, a dopamine agonist, was associated with a significant decrease in pain.was associated with a significant decrease in pain.

DysmenorrheaDysmenorrhea Dysmenorrhea, or painful Dysmenorrhea, or painful

menstruation, is the most common menstruation, is the most common complaint of gynecologic patients. complaint of gynecologic patients.

There are 3 types of dysmenorrhea: There are 3 types of dysmenorrhea: (1) primary (no organic cause),(1) primary (no organic cause),

(2) secondary (pathologic cause), (2) secondary (pathologic cause), (3) membranous (cast of endometrial (3) membranous (cast of endometrial

cavity shed as a single entity). cavity shed as a single entity).

Typically, pain occurs on the Typically, pain occurs on the first day of the menses, first day of the menses, usually about the time the usually about the time the flow begins, but it may not be flow begins, but it may not be present until the second day. present until the second day.

Nausea and vomiting, Nausea and vomiting, diarrhea, and headache may diarrhea, and headache may occur. occur.

DysmenorrheaDysmenorrhea

Treatment of Treatment of dysmenorrheadysmenorrhea

A. ANTIPROSTAGLANDINSA. ANTIPROSTAGLANDINS B. ORAL CONTRACEPTIVESB. ORAL CONTRACEPTIVES C. SURGICAL TREATMENTC. SURGICAL TREATMENT D. ADJUVANT TREATMENTSD. ADJUVANT TREATMENTS

Abnormal uterine Abnormal uterine bleedingbleeding

Abnormal uterine bleeding Abnormal uterine bleeding includes:includes:– abnormal menstrual bleeding abnormal menstrual bleeding – bleeding due to other causes bleeding due to other causes

such as pregnancy, systemic such as pregnancy, systemic disease, or cancer. disease, or cancer.

Patterns of Abnormal Uterine Patterns of Abnormal Uterine BleedingBleeding

Menorrhagia (hypermenorrhea) Menorrhagia (hypermenorrhea) Hypomenorrhea (cryptomenorrhea)Hypomenorrhea (cryptomenorrhea) Metrorrhagia (intermenstrual bleeding) Metrorrhagia (intermenstrual bleeding) Polymenorrhea Polymenorrhea Menometrorrhagia Menometrorrhagia OligomenorrheaOligomenorrhea Contact bleeding (postcoital bleeding) Contact bleeding (postcoital bleeding)

Evaluation of abnormal uterine Evaluation of abnormal uterine bleedingbleeding

A. HISTORYA. HISTORY B. PHYSICAL EXAMINATIONB. PHYSICAL EXAMINATION C. CYTOLOGIC EXAMINATIONC. CYTOLOGIC EXAMINATION D. ENDOMETRIAL BIOPSYD. ENDOMETRIAL BIOPSY E. SALINE HYSTEROSONOGRAME. SALINE HYSTEROSONOGRAM F. HYSTEROSCOPYF. HYSTEROSCOPY G. DILATATION AND CURETTAGEG. DILATATION AND CURETTAGE H. OTHER DIAGNOSTIC PROCEDURESH. OTHER DIAGNOSTIC PROCEDURES

Dysfunctional uterine bleedingDysfunctional uterine bleeding

TreatmentTreatment A. ADOLESCENTSA. ADOLESCENTS B. YOUNG WOMENB. YOUNG WOMEN C. PREMENOPAUSAL WOMENC. PREMENOPAUSAL WOMEN D. SURGICAL MEASURESD. SURGICAL MEASURES

Postmenopausal Postmenopausal bleedingbleeding

Postmenopausal bleeding may be defined Postmenopausal bleeding may be defined as bleeding that occurs after 12 months of as bleeding that occurs after 12 months of amenorrhea in a middle-aged woman. amenorrhea in a middle-aged woman. When amenorrhea occurs in a younger When amenorrhea occurs in a younger person for 1 year and premature ovarian person for 1 year and premature ovarian failure or menopause has been failure or menopause has been diagnosed, episodes of bleeding may be diagnosed, episodes of bleeding may be classified as postmenopausal, although classified as postmenopausal, although resumption of ovulatory cycles can occur.resumption of ovulatory cycles can occur.

Gynecologic causes of Gynecologic causes of bleeding bleeding

A. EXOGENOUS HORMONESA. EXOGENOUS HORMONES B. VAGINAL ATROPHY AND B. VAGINAL ATROPHY AND

VAGINAL AND VULVAR LESIONSVAGINAL AND VULVAR LESIONS C. TUMORS OF THE C. TUMORS OF THE

REPRODUCTIVE TRACTREPRODUCTIVE TRACT

Thank You !Thank You !