Diseases, Disorders information

The normal luteal phase, like I say, ovulation occurs. The corpus luteum cyst forms and produces both estrogen and progesterone and maintains the endometrium, makes it secretory, ready for a pregnancy. In discussing it with patients I will often times say, “Well, after you ovulate the endometrium becomes very thick and lush like a garden that has flowered and bloomed” and this is what we need to look for, especially when doing an endometrial biopsy. Now we can look at the phases of life as causing abnormal bleeding problems. They do occur in the pre-pubertal time, the reproductive time is when we see the most of them. There’s a fair amount of problems in the perimenopausal period, and this is because - for those of you who have been in practice since the advent of birth control pills - you’ll remember that during the 60’s, 70’s and early 80’s, we carried patients on birth control pills up until we figured they were in menopause and then we’d switch them over to hormone replacement therapy. Well, this changed out view of the perimenopausal period because their menses during the late 30’s and their 40’s were artificially controlled by the oral contraceptives. And we didn’t see the natural history. Nowadays we have more patients opting for sterilization procedures at a younger age. Then as these patients get into their 30’s, their late 30’s, get into their 40’s we start to see the natural hormonal fluctuations, occasional anovulatory cycles and so forth that then create irregular menstrual cycles, create menorrhagia and create menometrorrhagia, which is the natural history. If you go back and think about the patients in the 50’s and early 60’s that were in their late 30’s and their 40’s, many of them would have three, four or five D&C’s and then a hysterectomy for bleeding problems. And that’s the natural history in the perimenopausal patient. We can control that with oral contraceptives and did for years until somebody came out with the statement that every woman over 35 has got to come off birth control pills. I don’t know who started that rumor but it’s an ugly rumor and it’s untrue. In fact, oral contraceptives in this group of patients are extremely valuable in controlling menstrual cycles, in controlling the precursors of osteoporosis, because women start losing bone mass at the young age of 35. They already start going downhill and the oral contraceptives will prevent the loss of bone mass in that 35-50 year old age group before we put them on hormonal therapy. So I don’t know where it started, as I said, but it’s a dirty vicious rumor that you have to take women off birth control pills at the age of 35. You don’t do them any service. The last group, age-wise or lifestyle-wise, we see are the postmenopausal patients.
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Pre-pubertal causes usually, I think of foreign bodies because little girls and little boys explore themselves. Explore their genitalia. They like to put things …you always hear about them putting things in their nose. Little girls will put things in the vagina and they may have a foreign body. Very difficult to examine little girls, and probably there’s two easy ways to do it. Number one, if she’s a very good patient, you’ll have the mother lie down on the examining table and have the child lay on the mother’s abdomen with her knees up under her, sort of in a knee-chest position, you can sometimes spread the labia and with a light just look up the vagina to see if there’s anything up there. If I can’t get an exam done and the child is actually having bleeding and so forth, then my choice is to take them to the operating room, put them to sleep. You can do a good visual inspection and you can do a vaginoscopy with a cystoscope. It’s very simple, very easy. Sexual abuse is another thing that we think of and we look for signs of. Exogenous estrogen can be a problem. She may be picking up her mother’s birth control pills and having withdrawal menses because she takes a pill and after awhile, after a few pills that her mother didn’t happen to notice were gone, she stopped taking them and has some bleeding. Then of course we always worry about tumors, sarcoma botryoides, dysgerminomas and so forth.
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During the reproductive years: this is the group we see most frequently. Pregnancy and its complications is a frequent cause. Ovulatory problems only occur in maybe up to 25% of the patients. Anovulatory problems are the ones we deal with the majority of times. The patient is having either irregular anovulation or irregular ovulation, or is totally anovulatory. That can be 75% to 90% of the patients you see. And then anatomical problems in the reproductive years are usually fairly few and far between, although we do see a fair number of patients that have fibroids or cervical polyps or something like that, that are creating a problem. During the reproductive years the menarche usually occurs about the age of 12 now. It’s been dropping over the years. Ovulatory dysfunction is usually the problem with menarche and right after menarche. Inadequate endometrial response to estrogens, prolonged follicular phases, these young ladies are usually not ovulatory for the first year and a half to two years of their menses, so I kind of expect that many of these young ladies will have menstrual irregularities during the first year and a half to two years of their menstrual life. Like I say, anovulatory dysfunction is usually due to a failure to achieve ovulation. You have unopposed estrogens, endometrium keeps growing and growing but never matures, and then sloughs. We see extensive proliferation with inadequate stromal support when you do an endometrial biopsy.
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