I've never "liked" OB-GYN, so can someone who DOES/DID like it please help?

[Knicks]

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I'll most likely be posting my OB-GYN queries that require clarification in here, whenever they arise.

Let me start it off with this:

Dysfunctional uterine bleeding (DUB) is the most common cause of abnormal uterine bleeding.

Questions:

1- Why is it due to anovulation? (The menstrual cycle is something I understand, but I don't see how it [anovulation] is tied into DUB).

2- Why is progestin the treatment for MILD DUB with NO active bleeding?

3- Why is estrogen (high-dose) the treatment for MODERATE DUB with active bleeding?


I know the functions/roles of estrogen and progesterone in the menstrual cycle, but I can't make a connection with some of the pathologies. That's why I'm requesting clarification.

Thanks in advance.

 

[mglavin]

i didn't like it either but this is what I remember a resident telling me last year

estrogen = bricks
progestin = mortar

each menstrual cycle is like building a wall too many bricks and not enough mortar and it falls downs (bleeding). Too much mortar not enough bricks can cause it to fall down to (bleeding). Anovulation means no CL means no progestin means bleeding (bricks but no mortar). Treatment is to add mortar or bricks. I'm guessing that there are some nice clinical trials out there that explain why one is better then the other depending on amount of bleeding. Please correct me if I wrong but thats what I remember from ob/gyn over a year ago.

 

[Jolie South]

i didn't like it either but this is what I remember a resident telling me last year

estrogen = bricks
progestin = mortar

each menstrual cycle is like building a wall too many bricks and not enough mortar and it falls downs (bleeding). Too much mortar not enough bricks can cause it to fall down to (bleeding). Anovulation means no CL means no progestin means bleeding (bricks but no mortar). Treatment is to add mortar or bricks. I'm guessing that there are some nice clinical trials out there that explain why one is better then the other depending on amount of bleeding. Please correct me if I wrong but thats what I remember from ob/gyn over a year ago.

Yea, the big problem with anovulation is not really the bleeding but the continuous stimulation of the endometrium by estrogen which can predispose to endometrial hyperplasia and cancer. Progestin breaks that cycle, as would normally occur with a LH surge/ovulation. Well, it's not actually the progestin itself, but the withdrawal of the progestin that induces a bleed.

For that reason, you'd treat mild DUB with no bleeding with progestin.

If you have massive active bleeding leading to hemodynamic instability with DUB, estrogen induces contraction of the myometrium to stop the bleeding via a tamponade effect, I believe. Think about the yin and yang of estrogen and progesterone in terms of uterine contaction: estrogen is pro, progestin prevents. This makes sense if you think about how women with inadequate corpus lutei (sp?) will miscarry due to unopposed estrogen or how we give medroxyprogesterone to women with hx of preterm labor.

 

[Knicks]

Hmmmm.

Thanks guys for the input.

 

[THP]

A couple points of clarification:

DUB is actually a diagnosis of exclusion, ie when all other causes have been eliminated and we don't have a reason for the bleeding. If the cause of bleeding is chronic anovulation, that is your diagnosis.

As the others posted, if you don't ovulate you have prolonged periods of unopposed estrogen. This causes the endometrium to proliferate and "outgrow" its blood supply. As this happens certain portions begin to slough but because it is so thickened more sloughs than normal and it is not uniform (ie it sloughs from different parts of the uterus), so the bleeding can be prolonged.

During an acute bleeding episode you give high dose estrogen to rapidly make the endometrium uniform once again so that it can slough all at once (or you can do a d&c).

Its important for women with chronic anovulation and unopposed estrogen to be given a course of progestin and then stop it (usually after about 14 days) so that they can have a withdrawl bleed. This is so they don't have periods of heavy bleeding and it protects the endometrium from developing hyperplasia or cancer.

For what its worth, progesterone does stabilize the endometrium, however prolonged periods of low estrogen with high progestin can cause an atrophic endometrium which will also bleed.

Estrogen does not cause myometrial contractions and progesterone doesn't necessarily prevent them (otherwise we would use it as a tocolytic). Estrogen builds the endometrium and progesterone stabilizes it. When the progesterone levels fall the endometrium sloughs off. Think of progesterone as progestational.

Also, we don't give medroxyprogesterone (which is Provera - a progestin) for a history of preterm birth, we give 17-hydroxyprogesterone caproate.

Also, the whole concept of luteal phase deficiency has never been proven in the literature. There is no evidence for giving progesterone to women with recurrent first trimester losses. That being said, many REI docs do it knowing there isn't evidence for it because at some point you are trying anything to be successful.

 

[Knicks]

^^ wow, thanks a lot for that. I appreciate the further clarification.

 

[Knicks]

New question:

In FA it says that the high levels of LH in polycystic ovarian syndrome leads to anovulation. Why?
Isn't LH (high levels of it; surge) usually the cause of ovulation? So in PCOS, shouldn't you be ovulating?

I just have a problem with the wording. I mean, judging by the name of this disease, the ovaries are all messed up. But the part were FA says that high LH ----> anovulation got me.

Thoughts?

 

[ArcGurren]

New question:

In FA it says that the high levels of LH in polycystic ovarian syndrome leads to anovulation. Why?
Isn't LH (high levels of it; surge) usually the cause of ovulation? So in PCOS, shouldn't you be ovulating?

I just have a problem with the wording. I mean, judging by the name of this disease, the ovaries are all messed up. But the part were FA says that high LH ----> anovulation got me.

Thoughts?

High LH with low FSH is still not going to cause ovulation. LH is responsible for making more androstenedione in your follicular thecal cells and then the FSH causes upregulation of aromatase, which converts androstenedione to estrogen. With low levels of FSH you have lower conversion to estrogen -> causes hyperandrogenism -> virilization, hirsutism, infertility.

 

[Knicks]

High LH with low FSH is still not going to cause ovulation. LH is responsible for making more androstenedione in your follicular thecal cells and then the FSH causes upregulation of aromatase, which converts androstenedione to estrogen. With low levels of FSH you have lower conversion to estrogen -> causes hyperandrogenism -> virilization, hirsutism, infertility.

Brilliant.


Thanks!

 

[Knicks]

Another question (which may seem a little TOO obvious, but what can I tell ya?).....

If a woman just finished her monthly menstruation, a male can ejaculate inside her without worrying about getting her pregnant, RIGHT? (since her next ovulation will ideally be 2 weeks later, and since sperm survive for only about 2 days, right?)

Just wanna make sure/be safe, lol 😀

 

[BigRedder]

Another question (which may seem a little TOO obvious, but what can I tell ya?).....

If a woman just finished her monthly menstruation, a male can ejaculate inside her without worrying about getting her pregnant, RIGHT? (since her next ovulation will ideally be 2 weeks later, and since sperm survive for only about 2 days, right?)

Just wanna make sure/be safe, lol 😀

A woman with a "normal" cycle will ovulate around day 12-14. First day of menstruation is day 1. If menstruation lasts 5 days, then you are talking about day 6. Sperm might make it 3 days generally. So there you are at day 9. Probably no egg in sight. However, sometimes people aren't that regular, and from what I recall a lot of the variability in cycle length comes before ovulation in the follicular phase. So if that egg matures a bit faster... Hi daddy!

On a side note, as you are probably the 6 billionth "male" who has wondered about this, one might think that there is some sort of reliable answer on the internet. I don't know, I'm not an internet expert.

 

[Knicks]

A woman with a "normal" cycle will ovulate around day 12-14. First day of menstruation is day 1. If menstruation lasts 5 days, then you are talking about day 6. Sperm might make it 3 days generally. So there you are at day 9. Probably no egg in sight. However, sometimes people aren't that regular, and from what I recall a lot of the variability in cycle length comes before ovulation in the follicular phase. So if that egg matures a bit faster... Hi daddy!

On a side note, as you are probably the 6 billionth "male" who has wondered about this, one might think that there is some sort of reliable answer on the internet. I don't know, I'm not an internet expert.

ughhhh, why does everything have to be so complicated with women? 😳