Lecture

The reproductive system of the person is a functional

automatically regulating system which adapts to changes of an environment and an organism. The knowledge of the complex cyclic processes proceeded in reproductive system of the woman, allows to make representation about etiology and pathogenesis, a clinical picture of many gynecologic diseases and syndromes.

 Menstrual cycle -is repeating expression of activity of

hypothalamus - pituitary - ovarian system which is accompanied by structural and functional changes of a reproductive path: a uterus, uterine tubes, an endometrium, a vagina.
In womans organism there is not only a condition of hypothalamicpituitary-ovarian axis organs and target-organs changes, but also function of endocrinal

glands, vegetative regulation, a methabolism cyclically varies too, etc.

water-salt

As a whole almost all systems of womans organs

undergo more or less radical changes in connection with menstrual cycle.

 Varium et mutabile semper femina - the

woman - an essence always nonconstant and changeable Vergilium this aphorism can serve as a reminder to a doctor and as an epigraph to the big number of clinical researches.

 Menses - the end of normal biphasic

menstrual cycle.

Signs of physiological menstrual cycle:

1) biphasic, 2) duration more then 20 and less then 35 days, 3) cyclicity, 4) menses duration 2-7 days, 5) blood loss is between 50 and 150 ml, 6) absence of painful sensations and infringements of the general state of an organism.

 According to the historical tradition, the first level of regulation of reproductive system is considered targets-organs, the second - ovaries, the third - a hypophysis, the fourth - hypothalamus, the fifth and

the high - the areas of brains having connections with hypothalamus and influencing its functions, including a new cortex. However legitimacies of functioning of reproductive system are more convenient for considering in feedback order.

Regulation of menstrual cycle

The central and peripheral parts of reproductive system regulation

Extrahypothalamic parts of CNS Including neocortex Neurotransmitters and neuromodulators The menstrual cycle is regulated by brain cortex. Receiving of information from environment and interreceptions with neurotransmitter structures of central system sends impulses to neurosecretory hypothalamic nuclei.

 Hypothalamus Hypothalamic nuclei produce the specific neurohormones, which

stimulate pituitary (called as Liberins) and inhibit it (called Statins). Luliberin releasing hormone that stimulates luteonizing hormone (LH) secretion by the anterior pituitary Foliberin - releasing hormone that stimulates follicle-stimulating hormone (LH) secretion by the anterior pituitary Hypothalamic prolactin-releasing factors and depressing substances which contain dopamine

Pituitary Anterior pituitary produces gonadotropin hormones: Follicular-stimulating hormone, Luteinizing hormone, Prolactin, Other tropin hormones: Thyreotropic, Somatotropic, Adrenocorticotropic, Lipotropic, Melanotropic

Epiphysis: Melatonin limits foli- and lutropin production in the hypophysis. Ovaries: Sexual steroid hormones Targets-organs

Classification of disorders of development and function of generative system

(disorders of menstrual function)
1. Amenorrhea.

1.1.Primary amenorrhea. 1.1.1.Absence of sexual development. - malformations of gonads; - gonads dysgenesia (the Shereshevsky-Turner syndrome, Swyers syndrome); - erased form; - testicular feminizing syndrome (Moriss syndrome). 1.1.2. Delayed sexual development (infantilism): - hypogonadotropic hypogonadism; - hypergonadotrophic hypogonadism. 1.1.3. Without delay of sexual development: - Developmental anomalies of a uterus: an aplasia of a vagina and a uterus (Rokitanski-KustnerHausers syndrome).

1.2. Secondary amenorrhea: - hypogonadotropic hypogonadism; - hypergonadotrophic

hypogonadism; - psychogenic amenorrhea; - amenorrhea at loss of body weight; - anatomical (traumatic) lesions of a uterus, endometrial synechias (Ashermans syndrome).

 2. Hyperprolactinoemia. 3. Dysfunctional bleedings. 3.1. Ovulatory bleedings

4. Neuroendocrinal syndromes

(menorrhagia). 3.2. Anovulatory bleedings: - puberty dysfunctional bleedings (juvenile); - reproductive dysfunctional bleedings; - perimenopausal dysfunctional bleedings (climacteric).

(the most wide-spread): - Premenstrual syndrome; - Postcastration syndrome; - Climacteric syndrome; - Postnatal obesity syndrome; - Polycystic (sclerocystic) ovaries syndrome; - Adrenogenital syndrome; - Sheehan syndrome. 5. Endometriosis.

Classification of menstrual cycle disorders:

1.

Amenorrhea (absence of a menses) and hypomenstrual syndrome (scanty and infrequent menses) at the adult woman. 2. Cyclic disorders of a menses rhythm: ) opsomenorrhea, or bradymenorrhea - too infrequent menses (in 6-8 weeks); b) spaniomenorrhea - considerably prolate menstrual cycle (menses 2-4 times per year); c) proyomenorrhea, or tachimenorrhea - shortened menstrual cycle (menses in 1,5-2 weeks). 3. Change of blood volume that exudes during menses; ) hypermenorrhea - profuse menses, an excessive amount of blood, more than 100-150 ml; b) hypomenorrhea reduced amount of blood, less than 50 ml. 4. Disorder of mensess duration: ) polymenorrhoea - a lingering menses (7-12 days); b) oligomenorrhoea - a shortened menses (less than 2 days).

 5. Painful menses: ) algomenorrhea - pain during menses only in the sexual

system; b) dysmenorrhea - various common infringements at menses (headache, absence of appetite, vomiting, nausea, raised irritability, etc.); c) algodysmenorrhea - combination of an local and common pain during a menses. 6. Hemorrhagic metropathia - anovulatory monophase uterine bleedings. 7. trorrhagia - acyclic uterine bleedings, not connected with a menstrual cycle.

 8. norrhagia - the cyclic uterine bleedings connected to a

menstrual cycle and proceeding over 10-12 days. 9. Menometrorrhagia - excessive, prolonged bleeding that occurs at irregulary timed but scanty episodes of bleeding. 10. Intermenstrual bleeding refers to bleeding (usually not excessive) that occurs between otherwise normal menstrual cycles. 11. Precocious menstruation denotes the occurrence of menstruation before the age of 10 years. 12. Postcoital bleeding denotes vaginal bleeding after sexual intercourse.

Hypomenstrual syndrome (Mayers syndrome) opsomenorrhea, oligomenorrhea, hypomenorrhea.

Hypermenstrual syndrome (Shreders syndrome), or menorrhagia proyomenorrhea, polymenorrhea, hypermenorrhea.

AMENORRHEA

Amenorrhea absence of menses at adult women within

6 months.
Amenorrhea is a not independent disease, but a symptom

of many diseases, causing disorders of menstrual function regulation on different levels.

Classification of amenorrhea
Genuine (true) amenorrhea absence of cyclic changes in womens

organism, most frequently associated with acute insufficiency of sexual hormones. Physiological amenorrhea - absence of menses up to the puberty, during pregnancy, lactation, at postmenopause. Pathological amenorrhoea (primary, secondary) - a sign of gynecologic or extragenital diseases. Primary amenorrhoea - absence of a menses in the age after 16 years. Secondary amenorrhoea - absence of a menses during 6 months and more after of the period of regular or irregular menses. Pharmacological amenorrhea - the arrest of menses as a result of treatment. Falce amenorrhea (cryptomenorrhea latent menses) absence of menstrual blood excretion because of cyclic changes presence in organism (anatomic abnormalities athresia of hymen or vagina, athresia or aplasia of cervix of the uterus).

Kinds of amenorrhea:
Hypothalamic,
Hypothalamic-pituitary, Pituitary,

Ovarian,
Uterine, Adrenal, Amenorrhea caused by pathology of thyroid gland, Presence of extragenital pathology.

3 forms of an amenorrhea
In dependence of gonadotrophic Hormonums level:
hypergonadotrophic, hypogonadotropic,

eugonadotropic.

The primary amenorrhea:

- Timelagged sexual development, with infringement of

development of the secondary sexual attributes; - Without delayed sexual development.

Primary timelagged amenorrhea of a sexual

development.
Gonads dysgenesias (DG - a hypergonadotrophic

hypogonadism) absence of sexual development.

Typiform DG - ShereshevskyTurner syndrome (karyotype 45).

Clinic: specific morphotype, short body height (up to 150 cm), dysplastic constitution, expressed genital infantilism, delayed bone skeleton maturation, high level of gonadotropins, especially FSH.

Clear form DG - a karyotype 46 or 46 (Swyers syndrome)

Clinic: normal or high body height and proportional

constitution, no somatic dysplasia, primary amenorrhea, absence of breast development, indifferent structure of external genitals, morphotype can be eunuchoid or intersexual with moderately expressed hirsutism, high level of gonadotropins, secondary sexual attributes are underdeveloped on a background of the expressed genital infantilism. Gonads look like connective tissue rod, at Swyers syndrome - with elements testicles which can become malignant.

Blended form DG - a tesselated karyotype with obligatory presence of the chromosome (is more often - 45O/46Y) Clinic:

- normal or high body height with

features of masculanization, - primary amenorrhea, - absence or underdevelopment of breast, - morphotype intersexual, with moderately expressed hirsutism, the secondary sexual attributes are underdeveloped, a uterus sharply hypoplastic. In gonads there are elements of a testicular tissue.

 Erased form DG - a karyotype tesselated 45O/46.

This form is characterized by variability of clinical exhibitings.

Testicular feminization (Morriss syndrome, a false

man's hermaphroditism). Karyotype . female constitution, Developted big breasts, scanty pubic and axillary pilosis, vagina finishes blindly, external sexual organs develop like womens type, internal sexual organs absence (uterus, uterine tubes, ovaries).

The infantilism of hypothalamic-pituitary genesis (hypogonadotropic hypogonadism)

- is characterized by the low maintenance of

Gonadotropinums and absence of their cyclic secretion.

Isolated gonadotrophic failure - the especial form of delay

of sexual development at which isolated gonadotrophic failure is taped only. The clinic is characterized by eunochoid constitution, an underdevelopment of internal and external generative organs.

Organic affection of hypogonadotropic-pituitary system

 Cranyopharyngioma - a good-quality tumour which educes from a

peduncle of a pituitary body. The clinic is characterized by strong headache, a neurologic symptomatology. Treatment is operative.
Olfactgenital dysplasia (Kallmans syndrome, hypothalamic

hypogonadism) - the infrequent form of an organic pathology of hypothalamic-pituitary system - a combination of primary amenorrhea and anosmia. Treatment - a replaceable hormonetherapy.
Amenorrhea attached to adiposogenital dystrophy (Pehcrants

Babinsky Frelikh syndrome) develops in period of pubescence. Obesity with deposition of adipose tissue on thighs, abdomen, face, growth delay, hypoplasia of genitalia and intellect reduction are typical. Etioilogy is a tumor or trauma of hypothalamic region. Secretion of Luliberin, Folitropin, Lutropin decreases. Treatment: at tumoral etiology the treatment consists of ablation of tumor or in Xray therapy. After operation replacement hormonal therapy is used.

 Lorence Moon Barde - Bidle syndrome (hereditary

diencephal-retinal degeneration with autosomerecessive type of inheritance). Clinical symptoms are like the clinic of the Pehcrants Babinsky Frelikh syndrome. However, the main peculiarity of the patients is presence of drastic mental retardness (oligophreny), defects of development (polydactily, syndactily, pigmental retinitis). The patients have poor eyesights (sometimes total blindness), lowering of hearing or total deafness, scull anomalies, excessive development of fatty cellular tissue. Treatment: body weight lowering, hormonal therapy (thyreoid hormones, gonadothropic hormones, cyclic hormone therapy by oestrogens and gestagens).

Morghani Stuart syndrome

It is affection of hypothalamo-pituitary allotment as a result of

procrastination of Calcium salts in the region of turkish saddle (internal frontal hyperostosis). Clinic: headache, paroxysms of convulsions, psychic violations, obesity, virilism. Treatment is symptomatic.

Chiari Frommel syndrome persistent lactation syndrome

It is lesion of hypothalamic centers, producing Prolactin inhibiting

releasing-factor. Clinic: galactorrhea that begins after pathologic delivery or after abortion. High level of Prolactin that inhibits FSH production in its back, causes persistent lactation, lowering of oestrogens amount leads to amenorrhea, atrophy of exetrnal and internal genitalia, hypertrophy of breasts, disorders of carbohydrate and fatty metabolism, arterial pressure becomes unsteady. Treatment: hormone therapy, directed on inhibiting of lactation and regulation of menstrual function is applied.

Hende Shuller Krischen disease affection of hypothalamic pituitary system, autosomerecessive type of inheritance, nanism, sexual infantilism, exophthalmos, diabetes unmellitus, xanthomatosis, enlarged lymphatic nodes, serious sceleton changes. Treatment: sometimes X-ray therapy is used.

Pituitary amenorrhea

Amenorrhea at pituitary nanism Desease developsin prenatal period or during the first months of life due to infectious diseases or traumatic damages of anteriry part of pituitary. Insufficiency of all its hormones including somatotropin appears as a result. Treatment: growth stimulation, replacement hormonal therapy is indicated.

Amenorrhea at gigantism and acromegalia Diseases are cased by Somatotropin hyperproduction, prosuction of gonadothropic hormones is decreased. Amenorrhea has secondary character. Treatment: ft pituitary tumors rhoentgenotherapy is indicated. For patients with gigantism oestrogen therapy for stoping of excessive growth is prescribed.

Amenorrhea at Sheehan syndrome

develops after pathological delivery or septic diseases and

associated with hemorrhage into pituitary and following necrosis of its anterior, and sometimes also posterior part. Clinic: headache, giddiness, weakness, anorexia, later asthenia, body weight decreasing, amenorrhea and mixedema develops, head and pubis grow bald, arterial blood pressure and body temperature decrease. At deficit of gonadothropic hormones there are persistent amenorrhea, hypothrophy of genitals and breasts; deficiency of TTH: mixedema, growing bald, somnolence, worsening of memory; ACTH: hypotension, adynamy, weakness, intensive skin pigmentation. Treatment: anabolic hormones, replacement therapy (Prednisolon, Thyreoidin, Oestrogens, Progesterone).

Aplasia of a uterus (Mayer-Rokitansky-usters syndrome). The aplasia of the uterus is frequently combined with a vagina aplasia. Clinic - absence of a menses, in 40% there are developmental anomalies urine excretory system. Diagnostics - gynecologic inspection, ultrasonic, genetical consultation. Treatment is a colpopoesis. The resistant ovaries syndrome is the reason of a primary amenorrhea owing to insensibility of ovaries to gonadotrophic hormonus.

The secondary amenorrhea Results from a lesion at different levels of generative system. The secondary amenorrhea educes after the period of the normal or broken menstrual cycle. At this amenorrhea form infringement of the secondary sexual attributes development is not marked.

Psychogenic amenorrhea
This central form of an amenorrhea is accompanied by

development of an asthenoneurotic or astheno-depressive syndrome. At gynecologic and ultrasonic investigation normal development of internal generative organs is defined. Treatment is carried out by the gynecologist together with psychogenicinternist. Antidepressants, neuroleptics, vitaminotherapy with obligatory elimination of stressful factors are appointed.

Amenorrhea at loss of a body mass Clinic: decrease of a body mass on 15-25 % from age norm, a moderate breasts hypoplasia, external and internal generative organs. At loss of a body mass on 5-18 % menses are sharply stopped, without the period of an oligomenorrhea. If loss of the body mass proceeds, signs of a starvation accrue: the bradycardia, a hypotonia, hypoglicaemia, a hypothermia, a gastritis, constipations, then a cachexia educes with complete loss of appetite and a fastidium.

Endometrial synechias (shermans syndrome) owing to often, rasping currettages or endometritis.

Hyperprolactinaemia

- increase of production of Prolactinum a anterior lobe of a pituitary body and its level in a blood. Pathological hyperprolactinaemia educes owing to anatomical or functional infringements of a hypothalamic-pituitary complex.

The anatomical causes: - Tumours of a pituitary body (macro-and microprolactinomas); - Damage of a pituitary body peduncle owing to a trauma or a surgical intervention, a craniocerebral trauma, influence of radiation. The functional causes: - Neuroinfections (a meningitis, an encephalitis); - Endocrine diseases (a hypothyroidism, Kushings disease, an acromegalia). The iatrogenic causes (after reception of medicinal preparations): - The oestrogens, the combined oral contraceptives; - Drugs which influence a secretion and an exchange of Dofaminum; phenothiasinum, Haloperidolum, Metoclopramidum; - Drugs which exhaust stores of Dofaminum in CNS: Reserpinum, Methyldopa, monoaminooxydase inhibitors, opioids; - Stimulators serotoninergic system: an amphetamine, hallucinogens.

Dysfunctional uterine bleedings

DUB display of dysfunction of various parts of womans

reproductive system, are caused by infringement of rhythmic production of ovarian hormones are not connected to organic diseases of sexual system, with diseases of various systems of an organism. DUB - acyclic uterine bleedings with duration more than 7 days after the period of a delay more than 1,5 months. Morphological substratum of bleeding is more often hyperplastic endometrium. DUB - In structure of gynecologic diseases make from 10 up to 18%. From them the premenopausal period have 50%, the reproductive period - 30%, puberty - up to 20%.

Causes of DUB:

- neuropsychologic stresses; - mental or physical overwork; - nutritional factors (undereating, hypovitaminoses, household difficulties); - consequences of somatopathies (especially a liver, nephroses) and inflammatory processes of genitalias; - acute and persistent infections; - endocrine diseases.

Pathogenesis
In a basis of DUB pathogenesis in all age periods

infringements of formation and abjection of Gonadotropinums lay, which control a hormonal (and generative) function of ovaries. In puberty a gonadotrophic function was not generated yet. At reproductive age the cause of infringement of cyclic function can be stresses, infection contaminations, the hormonal infringements caused by an abortion, diseases of endocrine glands, some pharmaceuticals. In a climacteric a gonadotrophic function is broken because of the involutive processes.

Classification of DUB according to patients age:

- Puberty DUB (juvenile bleedings); - Reproductive DUB; - Perimenopausal DUB (climacteric bleedings).

Classification of DUB according to pathogenesis:

A. Anovulative (monophased) DUB. 1. Short-term follicle persistence. 2. The prolonged follicle persistence. 3. Follicle atresia. B. Ovulative (two-phased) DUB. 1. Hypoactivity of a corpus luteum. 2. Hyperfunction of corpus luteum. 3. Hypoactivity of a follicle which matures. 4. Hyperfunction of a follicle which matures.

Treatment of anovulatory DUB

Treatment is complex, differentiated, with due of the form

of disease, age, an expressiveness of anomaly. It is carried out in three stages: a haemostasis, a regulation of a menstrual cycle and regeneration of generative function or achievement of menostasis.

The common rules of therapy DUB:

1) fortifying therapy, 2) treatment of an anaemia, 3) symptomatic haemostatic and uterotonic agents, 4) consultation of interfacing experts and well-timed treatment of concomitant diseases. 5) physiotherapy: electrophoresis, endonasal electrophoresis of Thiaminum, Novocainum, Sodium chloridum of calcium, an electrical stimulation of cervix of the uterus, a laser irradiating, a magnetotherapy, a reflexotherapy.

 Fortifying therapy: work and rest order, that exclude a

possibility of physical and mental overloading; psychotherapy, sedatives and vitamin therapy.
Treatment of an anemia: antianemic preparations,

erythrocytes mass or fresh citrate blood at indications.

The hemostasis can be hormonal or surgical.

Hormonotherapy
method of treatment DUB is a hormonotherapy. Hormonums are directed at all three stages. The first stage - hormonal haemostasis Oestrogens, gestagens, their combination with androgens, synthetic Progestinums In predmenopausal period the hormonal hemostasis is adminitrateded only at presence of histological or cytologic inspection of endometrium.
Pathogenetic

Oestrogens haemostasis
due injecting of big doses of Oestrogens into organism, a suppression of

Folitropin synthesis in pituitary gland; acceleration of endpmetrium proliferation; decreasing of vascular walls permeability; retardation of fibrinolysis takes place by feed-back mechanism. Big doses cause ovulation blockade, the so called break bleeding appear at fast dose decreasing.

Indications: DUB of juvenile and reproductive age by hypoestrogeny type; anaemia and necessity of fast haemostasis; any term and duration of bleeding.
Drugs of natural oestrogens (Proginova, Microfollinum, Oestroferm) under

the schema of oral contraceptives in the course of a 2 weeks, then Progestinums (Dufaston, Utrogestan, Norcolutum) 10 days are used. The oestrogenic hemostasis is carried out at any age, only in premenopausal period after histological research of endometrium.

Gestagens haemostasis
is based on secretory transformation of endometrium and desquamation of

its functional layer (medicinal, hormonal curettage). Indications: short bleeding duration; absence of anemia and immediate haemostasis necessity. Gestagens haemostasis arrests bleeding or decreases it after progesterone introducing for 3-5 days, then it is increased again and continues for 8-9 days. At first secretory transformation of endometrium takes place (in this time bleeding decreases or stops), and then there is desquamation of its functional layer. More often the monophasic combined oral contraceptives are used for a hormonal haemostasis. Start with 4-6 tablets, gradually a dose reduces on 1 tablet in day, course of treatment 21 day. This kind of hemostasis is used in all age period of womens life up to 50 years. As gestagens promote an endometrium atrophya, anaemisation, to inhibition of the central effects, they are not used at youthful age, at anemia.

Androgens hemostasis
is caused by supression of hypothalamus and pituitary gland

function; blocking of follicle development in ovaries; antioestrogenic influence suppression of proliferation in endometrium; uterine vessels contracting; in myometrium (increasing of contractive activity). Indications: DUB of hyperoestrogeny type in climacteric age;uterine bleeding with contraindications for oestrogens prescribing (tumor in anamnesis, uterine fibromyoma, mastopathy). It can be used at the age over 45 before the artificial menostase; long application gives virilysing and anabolic effect.

Synthetic progestines haemostasis

blocking

of hypothalamus-hypophysis system and decreasing of foliberin and luliberin secretion; continuated haemostatic effect is caused by action of oestrogens and secretory transformations of endometrium under influence of gestagen component of the drugs. Indications: DUB at any age period.

Oestrogens and gestagens combination haemostasis

is caused by oestrogens effects (causes endometrium

proliferation) and gestagens transformation of endometrium).

effects

(secretory

Oestrogens, gestagens and androgens haemostasis

is connected, except listed above effects, with

progesterone-like influence of androgens on endometrium in big doses. Indications: non-ovulate DUB with follicle persistence. The disadvantages: non high therapeutic effectiveness, frequent relapses, method is contra-indicated at DUB with follicle atresia in juvenile age and in young women.

The second stage normalization of menstrual cycle and prophylaxis of relapse of bleeding. Especial value at the given stage has fortifying treatment. The third stage regeneration of genesial function, is carried out at women of genesial age. Antiestrogens, Gonadotropinums and Gonadotropinreleasing Hormonum are used.

Indications for surgical treatment (hysterectomy)

an adenocarcinoma endometrium,
combination DUB with relapsing adenomatose or an

atypical endometrium hyperplasia, adenomyosis nodulose form, a hysteromyoma.

NEUROENDOCRINAL SYNDROMES

Premenstrual syndrome

menstrual disease, a syndrome of a premenstrual strain. A

premenstrual syndrome - cyclically replicating, multiple pathological symptom-complex which appears in a few days before menses and is manifested in psychological, vegetovascular and metabolismendocrine disorders.

Reasons of a syndrome originating

1) acute and chronic contagions, 2) mental, intellectual overstrain,

3) pathological labors, abortions,

4) virus diseases, 5) pulmonary tuberculosis, 6) chronic, frequently relapsing salpingo-oophoritis.

Clinic
Signs of this syndrome occur for 2-14 days before menses

and disappear at once at the beginning or at its first day. It meets at 25-30% of able-bodied women in mild form and up to 50% at presence of a concomitant somatic pathology. The premenstrual syndrome for the first time was described in 1931 by A.Frank.

Theories of a syndrome originating:

a) hormonal,
b) aqueous intoxication, c) allergic,

d) theory of infringement of a function state of vegetative

nervous system. For today it is considered, that the premenstrual syndrome arises owing to infringement of neuropeptids metabolism in CNS (opioids, a serotonin, Dofaminum, Noradrenalinum) and peripheric neuroendocrinal processes connected to them.

The clinic is shown in three variants:

1.

Psychological distresses: a headache, a vomiting, a sleeplessness, irritability, depression, infringement of memory, sometimes aggressiveness (occurs in the second phase of a cycle in connection with an exuberant delay of fluid in a brain). 2. Vegeto-vascular infringements: palpitation, disorder of consciousness, a sweating, sensation of numbness in extremities, paresthesias. 3. Metabolismendocrine infringements - joint pains, edemas, breast engorgement.

Forms of premenstrual syndrome

- hydropic, - neuropsychological, - cephalgic, - crisis - atypical.

On a degree of course:
I - mild: occurs for 10-2 days, there are 5-7 signs, 1-2 are sharply expressed,

in the course of time amount is not enlarged;

II - severe: symptoms occur for 14 days, 5 and more signs are sharply

expressed, conserved and during a menses, after a menses 1-2 signs remain.

Hydropic: it educes at 20-25 years, breast enlargement, the meteorism, increase of a body mass, a sweating, an itch of a skin, decrease of Progesteronum, increase of Aldosteronum, a serotonin, Histaminum, a hydrocortisone in the second phase of a menstrual cycle. Psychological: it educes at women of 30-35 years, irritability, depression, aggressiveness, decrease of Progesteronum, rising of Prolactinum, Histaminum, a serotonin, a hydrocortisone, Aldosteronum, ACTH in the second phase of a menstrual cycle. Cephalgic: the age of women of 45-48 years, the basic sign is a headache of poured character, arching, squeezing, for phylum of a migraine, a nausea, skin is turn pale, at 40% relatives suffer an idiopathic hypertensia and a migraine, decrease of Progesteronum in the second phase leads to increase of Histaminum, a serotonin, Prostaglandinum 2, is combined with an osteochondrosis of a cervical part.

Crisis: the most serious, educes at women of 45-48 years, the symptomatology of an adrenal crisis, appearance of signs acute, without harbingers, rising the AP, an acute headache, a fever, comes to an end profuse urinary excretion, concomitant diseases of cardiovascular system, nephroses, a gastrointestinal path. Between crisises the AP raised, a headache, a nausea. It is typicaly a decrease of Progesteronum, rising of Prolactinum, Histaminum, Aldosteronum, decrease ACTH. Atypical: rise in temperature at the second phase of a menstrual cycle, a bronchial asthma, an allergic dermatitis, vision reduction.

Diagnostics:

state of hypothalamo-pituitary system is determined level of Prolactinum, Oestradiolum at both phases,

electroencephalography,
skull roentgenography, mammography at the first phase.

At cephalgic form: the eyeground is surveyed, the roentgenography of a skull, a turkish saddle, roentgenography a cervical part, an electroencephalography, consultations of the neuropathologist, the oculist are carried out.

At crisis form it is necessary to exclude a pheochromocytoma as at this form rising an epinephrine and Noradrenalinum is marked, urine on catecholamins is researched, ultrasonic of paranephroses is carried out.

Algodysmenorrhea
the pathological condition described as a combination

painful menses with cyclically arising common somatic disorders.

Classification
- Primary (constitutional, essential); - Secondary Primary it is connected to functional infringements in immune,

nervous, endocrine systems, water-salt balance. Secondary it is caused by one of the following diseases: - Endometriosis, - Inflammation of internal genitals, - Incorrect position of internal genitals, - Anomalies of development of genitals, - Sexual infantility. Last reason is the most often in the second subgroup.

 Despite

of distinctions in etiology of development of algodysmenorrhea, there are common pathogenetic features for both groups: - Attributes of the vegetative neurosis caused by increased impulses from internal genitals, decreased painful sensitivity threshold, increased sympatho-adrenal system tone (less often parasympathetic).

Accompanying factors of algodysmenorrhea development:

- increased synthesis of prostaglandins, - Prolactin surplus, - sexual hormones surplus, - inadequate hormonotherapy, - organic changes in genitals, - overwork, - type of the supreme nervous activity.

Clinic:
There are characteristic signs of algodysmenorrhea: - Intensive pains in a lower part of abdomen, - Significant deviations in activity of a gastrointestine path, - Significant deviations in activity of heart, - Significant deviations in activity of other bodies. In total there are more than 30 symptoms. More often pains arise with approach of menarche, less often - the next years, even less often - 1-2 years prior to occurrence of menses. Thus, a leading symptom - contractive pains in lower part of abdomen, in sacrum, with irradiation in inguinal and femoral areas, rectum. More often the pain arises before menses or at the beginning of menses, is rare - at the end.

The general symptoms:

- Headache, - Nausea, - Vomitting, - Depression, - Aggression, - Hypersalivation,

- Constipation, - Meteorism, - Sweating, - Chills, - Hypostases, - Arthralgia, - Polyuria, etc.

For all symptoms cyclicity of occurrence and

spontaneous disappearance are characteristic.

Primary algodysmenorrhea
Etiology and pathogenesis of primary algodysmenorrhea

are investigated worse, than secondary, and the clinic differs a variety.

The first type

arises at teenage, and also in more advanced ages, in the course of time

clinical displays can amplify. Contractive pains remit after allocation from a uterus a rejective endometrium. Treatment: oestrogens at I phase of a cycle, spasmolitics up to and during menses, hormonal drugs for suppression of ovulation 3-4 months.

The second type The second type

has central genesis. It arises owing to overfatigue, asthenia, wrong education

of the girl (excessive fixing of the girl on own experiences). Treatment: sedative, desensitized therapy, diuretic drugs before menses, Kalium, vitamin , psychotherapy.

The third type

arises at anovulative cycle. Treatment: restoration of a biphase cycle,

spasmolitics.
At all variants are shown a bed-regime, analgetics, spasmolitics, correction

of a water-salt metabolism, inhibitors of prostaglandins synthesis (indometacin, aspirin). Hormonotherapy it is appointed only after inspection of the hormonal status of the patient.

Secondary algodysmenorrhea
- it is considered as one of symptoms of the main disease:

inflammations of genitals, tumours or anomalies of development of genitals, an endometriosis, sexual infantility.

Climacteric syndrome

Climacteric (from Greek - manway) - acclimatization of

an organism to new conditions is shown by involution of the highest nerve centers and sexual system with the gradual arrest of menstrual and generative functions.

 Premenopausal period - 38-40 years before appearance

of irregular cycles. Perymenopausal period - from appearance of irregular cycles up to absence monthly within 12 months. Menopause - absence monthly within 12 months. Postmenopause - in 12 months after last menses till 60 years.

 The clinical period, climacterium, is divided in two

phases.

The first phase - the period of infringements of menstrual

function (from appearance of changes of a cycle before a menopause).

The second phase - a menopause. During 3-5 years after

offensive of a menopause hormonal function of ovaries proceeds, in the first 2-3 years follicles can mature. A pathological climacterium is still evolved: early - till 40 years, late - after 50 years.

Clinic
Course of a climacterium and a menopause can be simple

and complicated, with exhibiting various complaints which joint in concept a climacteric syndrome. Pathological course of a climacteric syndrome in 50-80% is preceded with fixed signs premenopausal and the climacteric period:

1. Early signs (vasculomotor)

- a sweating, affluxes which are accompanied by an intensive

dermahemia of the person which is replaced by an profuse diaphoresis, distress of dream, irritability, depression, infringement of concentration of attention, a giddiness, joint pains, palpitation, affluxes. These signs are caused by decrease of an estrogens level.

2. Middle temporal
- dryness of a vagina, a pain at sexual contact, a urethral syndrome,

a xeroderma, a fragility of nails. Up to 25% it is marked hypoestrogenya. A relaxation of muscles of a pelvic bottom, a ptosis of generative organs, an urinary incontinence. After 60 years almost at all women the urinary incontience, in the beginning - stressful, then constant is marked.

3. Late metabolic pathological changes:

ischemic disease, an osteoporosis.

Degrees of climacteric syndrome gravity:

- Mild - affluxes up to 5 times in day;

- Moderate - affluxes up to 15 times in day;

- Severe - affluxes more than 15 times in day.

Treatment

In a nem 10-50% of women require, it should be individual. I stage - not medicamental: - Fortifying treatment 1) a hygienic regimen - a diet, hydrotherapeutic procedures, pine needle baths, air; 2) a psychotherapy; - Physical methods of treatment: 1) morning gymnastics for 15-20 minutes, medical gymnastics 3 t/week till 30-40 min, massage; 2) anodic galvanization of a brain, cervical-facial or intranasal iongalvanization, a galvanic collar with Novocainum, Calcium chloratum, Bromum, magnesium (15-20 sessions on 15 min); 3) impulse currents on a method of an electroanalgesia (electrodream); 4) acupuncture; 5) balneotherapy (salt-alkaline, pine needle baths); - A vitamin therapy: A, 1, C, . II stage - consultation of the neuropathologist; Reserpinum, Obsidanum, Stugeronum, cholinolytices, Belladonna, Belloidum, Bellataminalum, Tavegilum, homeopathic drugs of hormonal action (climactoplanum, climadinonum). . III stage - a hormonetherapy Replaceable hormonal therapy in treatment of a climacteric syndrome is pathogenetic and should be a basis of treatment-andprophylactic complexes, naturally, under condition of absence of contraindications. Absolute contraindications for administration of oestrogens: - A mamma cancer, - Serious distresses of a liver function, - A porphyria, - An endometrium cancer in an anamnesis. Absolute contraindication for administration gestagens - a meningioma. Gestagen drugs which are used for treatment of a climacteric syndrome, are divided on 3 bunches: derivants of 17-OH Progesteronum (climenum, divina, divitrenum, femostonum and etc), derivants 19-nortestosterone (climonorm, cycloproginova, kliogest), natural Progesteronum (dufastonum, utrogestanum, Norcolutum). Climonorm, cycloproginova - are administrated from 38 years in premenopause and perimenopause without the expressed attributes virilization. Climen - has antiandrogenic action. Tibolonum, livialum they ar administrated in a postmenopause or at women with the low maintenance of androgens. Trisequens - after 40 years also is more senior at the preserved menstrual cycle, reduced libido. Cliogest - after 50 years, not earlier, than in one year after last menses, it is long. Divitrenum - it is administrated not earlier, than in one year after last menses, yields 3 menses in one year.

Absolute contraindications for administration of oestrogens:

- A mamma cancer, - Serious distresses of a liver function, - A porphyria, - An endometrium cancer in an anamnesis.

Absolute contraindication for administration gestagens - a meningioma

Gestagen drugs which are used for treatment of a climacteric syndrome, are divided

on 3 bunches: derivants of 17-OH Progesteronum (climenum, divina, divitrenum, femostonum and etc), derivants 19-nortestosterone (climonorm, cycloproginova, kliogest), natural Progesteronum (dufastonum, utrogestanum, Norcolutum). Climonorm, cycloproginova - are administrated from 38 years in premenopause and perimenopause without the expressed attributes virilization. Climen - has antiandrogenic action. Tibolonum, livialum they ar administrated in a postmenopause or at women with the low maintenance of androgens. Trisequens - after 40 years also is more senior at the preserved menstrual cycle, reduced libido. Cliogest - after 50 years, not earlier, than in one year after last menses, it is long. Divitrenum - it is administrated not earlier, than in one year after last menses, yields 3 menses in one year.

Polycystic ovarian
Polycystic ovarian syndrome (PCOS) or disease (PCOD) Stein-

Leventhal syndrome. In 1935 by Stein and Leventhal have described a symptom-complex which is characterized by a triad of signs: infertility, a hirsutism, an obesity at presence cystchanged ovaries. For today on the establishment of researches it is fixed, that at these patients, except for the expressed infringements in leading parts of genesial system, are defined long metabolic consequences of chronic novulation. 40% of women with PCOS are at reproductive age and have obesity, have infringements of tolerance to a glucose or a diabetes, at pregnancy at them the risk of development of Diabetum pregnant grows. Anovulation, hyperandrogenia and hyperinsulinemia, characterizing PCOS, form man's a profile of risk factors of development PCOS.

Portrait of Magdalena Venturra with the husband and the son (fragment). Khose Ribera. Toledo. 1631.

Classification
The first form initial sclerocystosis ovaries: hypermenstrual anovulatore cycle, moderate relative hypooestrogenia, a normal secretion 17-S, and 17-OKS, a moderate hirsutism, an endometrium proliferation or dysplasia; The second form sclerocystosis ovaries is accompanied by an adrenogenital syndrome, infringement of a menses for phylum of an opsomenorrhea or an amenorrhea, without dysfunctional bleedings, with the expressed hirsutism and elements virilism (increase of a clitoris and a uterus hypoplasia), an endometrium hypoplasia or an atrophy; The third form it is connected with neurometabolic infringements of a hypothalamopituitary genesis; an obesity, a moderate hirsutism, an arterial hypertension, rising of paranephroses cortex function, infringement of menstrual function for phylum dysfunctional uterine bleedings, augmentation of ovaries, a uterus, a hyperplasia endometrium, and sometimes atypical hyperplasia.

Ethiology
is not found out up to the end for today. Causative factors:

genetical, perinatal, psychogenic, endocrine. Ovarian genesis are connected to enzymatic defects - infringement of synthesis of Progesteronum from Pregnenalonum, or ferment defect in ovaries invokes failure of synthesis of oestrogens and Progesteronum. Thus, conditions for accumulation of androgens are frameed, that in turn invokes stimulation FSH and results in development an ovaries sclerocystosis. Probably, infringement in a hypothalamus, and also in ovaries invokes infringement for phylum of a feed-back. There is also an adrenal theory.

Clinic:
infringement of menstrual function, anovulatore infertility,

a hirsutism. Age of sick-20-30 years. At 1/3 patients - an obesity. Diagnostics: an anamnesis, the objective status, laboratory, clinical researches. A laparoscopy: the ovaries are often bilaterally enlarged (4-3-2 cm), with thick capsule, the surface may be lobulated but the peritoneal surface is free of adhesions, multiple cysts 0,5 o 1,0 mm at times up to 20 mm in size are localized along the surface of the ovary giving a necklace appearance on ultrasound. These are atretic follicles. Theca cell hyperplasia is seen which produces excess of testosterone secretion.

 On today gold standard of diagnostic criteria PCOS is not

present. The general survey of the patient allows to reveal presence and a degree of a hirsutism. Akanthosis nigricans on a neck, in axillary and inguinal ranges there is a characteristic attribute insulinresistense. Infringement of a Gonadotropinums secretion: rising of level LH at reduced or datum level FSH, - characteristic attribute PCOS. At PCOS index LH/FSH is more 3. Sensitivity is defined to an insulin, lipid a profile of a blood, as dyslipidproteinemia - a risk factor of development PCOS.

Treatment
Treatment is individual, can be hormonal and surgical. First of all for

the patient with PCOS and obesity it is necessary decrease of body mass that it is a connatural method of sensitization to insulin. At decrease of a body mass on 5% in 60-80% at patients with hyperandrogenemia and anovulation the regular menstrual cycle is recovered due to decrease of an insulin concentration. At absence of effect from conservative therapy - surgical treatment. From surgical methods of treatment - a clinoid resection of ovaries, is removed 2/3 or part of an ovary. Recently it is successfully used term-and an electrocauterization of ovaries, laserpuncture during a laparoscopy. After operative treatment the menstrual cycle is restored in 95% of cases, genesial function - in 85%. During pregnancy misbirths, premature labor, complications in labor are possible.

Sheehan syndrome
This syndrome is shown an amenorrhea which is caused by

failure of an adenohypophysis, it is described in 1939 y by Sheehan after a massive hemorrhage in labor. At massive blood loss there is a retardation of a blood-groove (a circulating collapse) with a deep infringement of circulation in diencefalpituitary range owing to an ischemia, an aseptic clottage of pituitary body vessels, and further its necrosis with destruction of mainly anterior lobe of a pituitary body with abaissement of gonadotrophic Hormonums. Adenohypophysis failure can be owing to an embolism and a clottage of pituitary body vessels, a tumour, a trauma, contagious processes in a pituitary body, a hypothalamus.

Clinic:
failure of paranephroses (delicacy, an adynamia, an anorexia, a

nausea, a vomiting, pressure decrease, hypoglucemia attacks), absence of a lactemia, a mammas atrophy, failure of a thyroid gland and ovaries, abaissement of a hair. In serious cases the diabetes, infringement of a thermoregulation, vegetative distresses, growing thin up to a cachexia, mental infringements educe. Treatment Replaceable therapy by corticosteroids, thyroid, sexual Hormonums, anabolites (Nerobolum), Cortisol-Acetas, Prednisolonum, Hidrocortizonum, Thyreoidinum, cyclically sexual Hormonums. Prophylaxis consists in the prevention and well-timed treatment of bleedings and septic states.

Forbes-Albright syndrome
It is arises at tumours or a hyperfunction of a pituitary

body, is shown an amenorrhea, a galactorrhea which is not connected to labor as against Chiari-Frommel syndrome. It is frequently combined with obesity, a gigantism, basically due to extremities, acromegalism and a hirsutism. Treatment is surgical or radial therapy.

Adrenogenital syndrome
It is characterized by appearance virilism an adrenal genesis. Clinical forms:

congenital, postnatal, postpuberty. Disease is hereditary also is caused by failure of ferment systems which monitor synthesis of glucocorticoids in paranephroses cortex. Congenital AGS is shown a female pseudohermaphroditism. External generative organs of the girl remind male: augmentation of a clitoris, a underdevelopment of small and big vulvar lips. There are expressed hirsutism, roughening voices, mammas are underdevelopment, body height of girls low, a disproportionate constitution of a trunk, wide shoulders, a fine-bored pelvis, short extremities, a subcutaneously-fatty tissue is diminished, a body muscles are hypertrophied.

Diagnostics
The

increased maintenance hypooestrogenia.

in

diurinal

urine

17-S,

17-OKS,

Treatment
It is carried out with the count of the patient age, anatomical changes of

paranephroses. Prednisolonum or Dexamethazonum is applied during one year and more.

Postcastration syndrome
Postcastration syndrome - a complex vegetovascular,

psycoaffective and the metabolicendocrine infringements arising after total or subtotal ovariectomy in a combination to removal of a uterus or without removal. PCS it is observed at 60-80% women after operations in connection with tumours of a uterus, appendages of a uterus, purulent tubo-ovarian formations. In the literature there is a term a surgical menopause. The surgical menopause is the arrest of menstrual function in connection with erasion of ovaries, ovaries and a uterus or only a uterus whereas PCS arises only after ovaries removal - a total or subtotal castration.

Diagnostics
On the base of an anamnesis, a clinical pattern.

Treatment is carried out stage by stage, with the count of an extragenital pathology, age and volume of an operative measure, treatment complex and includes not medicamental, medicamental not hormonal and replaceable hormonal therapy. Replaceable hormonal therapy of a syndrome is pathogenetic (interchanges products of a secretion of the removed members), is appointed at absence of contraindications. The purpose of treatment - elimination vegetovascular, psychoemotional and urogenital signs in the postoperative period to provide prophylaxis of the remote consequences of loss of estrogens (cardiovascular diseases, an osteoporosis, Alzheimer disease).

Variants of duration of replaceable hormonal therapy

1.

Treatment is directed only on elimination of early signs postcastration syndrome. Duration of course of treatment of 3-6 months, with repetition of such courses. 2. Long treatment is directed on protection of osteal system, vessels of a brain, 5 years and more proceed. Pathes of introduction of hormonal drugs for replaceable therapy: peroral, transdermal, vaginal, implantation, aerosol. Gestagen drugs which use for treatment PCS. Share on three bunches: derivants of 17-Progesteronum, derivants 19-nortestosteronum, natural Progesteronum. Monotherapy by estrogens is recommended only after a hysterectomy if histerovarectomia it has been executed in connection with an endometriosis. Drugs which do not yield a bleeding of regeneration (cliogest, livial) are administrated. Estrogens are administrated courses for 3-4 weeks with 5-7 diurnal rests, time in 3 months - 10 days natural Progesteronum (dufastonum, utrogestanum). It is necessary to carry out the control over a state of mammas (ultrasonic, a mammography), endometrium, arterial pressure, factors of a blood coagulation.

Thanks for attention