Pathophysiology

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The physiology of the normal menstrual cycle depends on a coordinated system of hormonal interactions involving the hypothalamus, anterior pituitary gland, ovary, and endometrium. Figures 49-1 and 49-2 summarize these points. Pulsatile gonadotropin-releasing hormone (GnRH) secretion from the hypothalamus stimulates the anterior pituitary to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In the specialized cells of the ovarian follicle, FSH and LH stimulate the release of estradiol. Estradiol stimulates endometrial growth during the follicular phase of the cycle. Following the LH surge and ovulation, the follicle is transformed into the corpus luteum. Progesterone that is secreted by the corpus luteum during the luteal phase of the cycle causes endometrial "organization." If conception does not occur, the drop

in estrogen and progesterone stimulates the shedding of the endometrium.

Table 49-1 illustrates the pathophysiology of amenorrhea relative to the organ sys-tem(s) involved, as well as the related condition(s) that result in amenorrhea. Amen-orrhea is also an expected, potential side effect resulting from the use of low-dose oral contraceptives (OCs), extended-cycle OC pill use, or depo medroxyprogesterone acetate (MPA) use.8 Many women may experience delayed return of menses after discontinuation of OCs. Postpill amenorrhea usually is a self-limited condition. Further evaluation for other unrecognized conditions, such as polycystic ovary syndrome (PCOS), should be considered if spontaneous resolution of the amenorrhea does not occur within 3 to 6 months following discontinuation of the OCs.

FIGURE 49-1. Summary of the normal menstrual cycle.
FIGURE 49-2. Hormonal fluctuations with the normal menstrual cycle. (From DiPiro JT, Talbert RL, Yee GC, et al., (eds.) Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill, 2008.)

Table 49-1 Pathophysiology of Selected Menstrual Bleeding Disorders

Organ iytlem

-Condition

Palhophyiloloçy/Labofamry fin-dings inKTorrtiM

Uterus

Oeries

Artlei hji piftiiniy

Hypolîwiarnus

Anovulatory bleeding tt^slütogic causes

Ashetman^ syndrome iIijrM |cni|.>l utiTirX" ibflflfltWBliei "Turner's syndroms Oorwitel dysgene^

:>i--nVilyiiLcyi,iirLi'i lolling

Che mothci an y/radiation fWui»iVIJrtite<firr5eWîïilHJ ü^ivia Hypolliyioidisrn

Medtatiom—wUpsycteto. wapsmll

"■funcliuniir hypothalamic ■tmn.'narrhe.a

Disordered eating

AnovukUkjFVKi»

Adolescence Aenmnvifiauie l^ostcnK^lage/postttJigiral uterine adhesions AljnoiiKill utrtirX1 [Jivik^nWH Lack of ovarian follicles Other geneix sntjrvisli?; fatly tan o' fattcltf Gonadol i-Lj<inv 1 pioiji tin iuhwssh y i it> 1RH causing t proljt tin, othci abnoiimltlles T Prolactin i.uiififL-'«^ HH) .lift I Pulsatile GnHH st-tittio" in the jbsttKO oi Mhet it^nnjlili« J- Pulsatile GinFlM secretion 4 fit I are) HI secondary to lass

I Pufeilll* CinHH y.-iitfio«, Il-SH ind LH iti^nJiry to low body fit

Asynclironoutgonadolropin jnd eslrogen production. atYKvmal «ldanieinal growth

Immafcitty ct the hyponhalamic-pituliary-ovjiran amis;

Mo LM surge l>?clining (warian function

I*jllicileyit <JHV04

HairkHatoyk:

HifMClC

E"tkx.l inc

LJWfiiK?

Hypothalamic dyifundion (physical of aiKHlOflll 4ii«i. onTfiv?. mPK)lin lni.s) Hyptf prolactinemia (piluilfy [jljnd

[limfx, fj^j-c hlflii ir Hypoltyioidnm ItomaLuKf ovarian iailunf von ViW&brartd'i diwaMi idiopathic thrombocytopenic puipura

OrtnA HyuOllvyiOkJiim Fibroid? ¿dentn^tHii bndcxwtrial polypi t^riMKilLigK: oranre

HypWtfrOQPftbtt Hljplh WStOKtriHTi, liicjln IH

hgfHTlnsutnefiift 6nd insulin resisianiie Suppression c* ptilsjlil? QriBi I secretion and eslicge^i

(JMiL'ft'rliy: low IK leW^ffl High pr«UkLCin

High T5H High HSU

Fjt ;or VII (Jcfixl cauuny Impaired p)Jlekl Jtlifiiun and iiiCiws«ltilrt<liiiy lime Deosase m crciibting platelets—can be acute 01 chronic

OKifni'jvJ I'Mrmiifi IWMlH )I|4I1\ I.jltiifiyii i: I Cr^atjuloflArh^

Ahenmentin HPOJBS

Alter pi ijn of (Innr^ In t^ifrirW.WflfrilCtlllty

Alter91 ion of entjornelirfin changes in ulciine contractility Alter al ion of ondomeliMm

WarkXH Hrfplail*: alieraiofii of endometrium UHIUE, cetvlu t. hlgP\ X, lovo; flu fc* h' ittrulailfig noimono. ^inftH gorudouopiii i ■ ■-.-.i :,inq hofmoneiHPQ, h^pollu^iifc-pllumi/-ovarian aMS. LH, luteinizing honrone; PC05. polyc/iticovfliy disease; TBI, thyrohopin leasing hormoiie; T5I-I, thyToid stimulating hormone.

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