Disorders of Menstruation: Amenorrhoea

Menstrual abnormalities are:

• Amenorrhoea
• Dysmenorrhoea
• Polymenorrhoea/ Epimenorrhoea
• Oligomenorrhoea
• Menorrhagia/ Hypermenorrhoea
• Polymenorrhagia
• Metorrhagia/ Metrostaxis
• Menometrorrhagia
• Hypomenorrhoea

Amenorrhoea

Definition: Amenorrhoea means absense of menstruation. 

It is a symptom and not a disease.

There are at least five basic factors involved in the onset and continuation of normal menstruation. These are:

1. Normal female chromosomal pattern (46XX
2. Coordinated hypothalamo-pituitary-ovarian axis
3. Anatomical presence and patency of the outflow duct.
4. Responsive endometrium
5. Active support of thyroid and adrenal glands.

Clinical Types of Amenorrhoea:

A.  Physiological:

1. Primary amenorrhoea
   
   • Before puberty: The pituitary gonadotrophins are no adequate enough to stimulate the ovarian follicles for effective steroidogenesis-==>Oestrogen levels are not sufficient enough to cause bleeding from the endometrium.
2. Secondary amenorrhoea
   
   • During pregnancy: Large amount of oestrogens and chorionic gonadotrophins secreted from the trophoblasts suppress the pituitary gonadotrophins.==>No maturation of the ovarian follicles.
   • During lactation: High level of prolactin inhibits ovarian response to FSH. So no follicular growth occurs.==>Hypo-oestrogenic state==>no menstruation.
   • Following menopause: No more responsive follicles are available in the ovaries for the gonadotrophins to act. As a result, there is cessation of oestrogen production from the ovaries with elevation of pituitary gonadotrophins.
    

 B.  Pathological: 

1. Concealed (cryptomenorrhoea)
   
   • Congenital
   • Acquired
2. Real (True)
   
   • Primary
   • Secondary
   
   
   
   

    Primary Amenorrhoea

   Definition: Primary amenorrhoea is the absence of menstruation by 16 years of age in the presence of normal secondary sexual characteristics, or by 14 years of age if secondary sexual characteristics have not been developed.

   
   

   Causes of Primary amenorrhoea:

   
   
   
   

Anatomy of Uterus, Supports of Genital Organs

The uterus is a hollow pyriform muscular organ situated in the pelvis between the bladder and the rectum behind.

Anatomy of Uterus:

A.  Position: Its normal position is one of the anteversion and anteflexion.

B. Measurement: It is about 8 cm long and 5 cm wide at the fundus and its walls are about 1.25 cm thick.

C. Parts: Uterus has got 3 parts:

1. Body or corpus: Fundus and body proper
2. Isthmus
3. Cervix

D. Structures: The wall consists of 3 layers form outside inwards-

1. Parametrium: It is the serous coat which invests the entire organ except on the lateral borders. The parametrium is intimately adherent to the underlying muscles.
2. Myometrium
3. Endometrium

E. Blood supply of uterus:

• Arterial supply:
  
  • One on each side arises from the anterior division of the internal iliac artery directly or as a branch of the hypogastric artery.
  • Ovarian and vaginal arteries: It anastomoses with uterine arteries. 
• Venous Drainage: Corresponds to the arterial supply and drains into Internal Iliac veins.

F. Lymphatic drainage of uterus:

• Body of the uterus:
  
  • From the fundus and upper part of the body of the uterus- Aortic and lateral groups of glands.
  • Cornu- Superficial inguinal gland along the round ligament.
  • Lower part of the body: External iliac group
   
• Cervix:
  
  • External iliac, obturator lymphnodes either directly or through para-cervical lymph nodes.
  • Internal iliac groups
  • Sacral groups 

G. Nerve supply of uterus:

• Sympathetic supply: T5 and T6 (motor) and T10-L1 spinal segments (Sensory). 
• Parasympathetic supply : S2-S4 spinal segments.(mixed)

Now we will discuss the supports of Genital organs:

Supports of the uterus:

A.    Primary Supports:

1. Muscular or active support of Uterus:
   
   • Pelvic diaphragm
   • Perineal body
   • Urogenital diaphragm 
2. Ligamentous (Fibromuscular or Mechanical) support
   
   • Transverse cervical ligaments of Mackenrodt or Cardinal ligament
   • Uterosacral ligament
   • Round ligament of the uterus
   • Pubocervical ligament
   • Uterine axis

B.    Secondary supports formed by peritoneal ligaments

1. Broad ligament
2. Uterovesical fold of peritoneum
3. Rectovaginal fold of peritoneum

Supports of Vagina:

1. Upper part by the lower components of the transverse cervical ligaments of Mackenrodt or cardinal ligament
2. Lower vaginal part by the:
   
   • Fibres of the levator ani muscle
   • Urogenital diaphragm
   • Perineal muscles
3.  Anterior vaginal wall by pubocervical fascia
4. Posterior vaginal wall by perineal body and rectovaginal fascia

The Fallopian Tube:

 The fallopian tubes are two tortuous ducts which extend from the ovaries to the cornua of the uterus, one on each side.

Fallopian tubes are also called Uterine tubes or Oviduct.

Anatomy of Fallopian tube:

Length: 10 cm.
Situation: Each lies in the free upper border of the broad ligament of the uterus.
Extension: Its lumen communicates with the uterine cavity at its inner end and with the peritoneal cavity outer end.
Parts: Four parts:

1. Interstitial or intramural part: 1-2 cm in length and is the part which traverses the uterine wall. It gets no peritoneal coat.
2. Isthmus: Straight and narrow portion adjacent to the uterus and measures 2-3 cm in length.
3. Ampulla: Wider thin walled and tortuous outer portion, approx. 5 cm in length. It leads to the infundibulum.
4. Infundibulum: Trumpet shaped outer end of the tube with and opening into the peritoneal cavity (abdominal ostium). The ostium is surrounded by fimbriae, which moves freely and are devoid of broad ligament and pick up ovum when release from ovary.

Structure of Fallopian tube:

1. Serous layer: Derived from peritoneum.
2. Muscular layer: Outer longitudinal and inner circular layer of involuntary muscle.
3. Submucous layer: Delicate connective tissue which separates the muscle zone from the mucosa lining of the lumen (Endosalpinx).
4. Mucosa: Lined by ciliated columnar epithelium. Mucous membrane is thrown into complicated folds which fill up the lumen of the tube.

Blood supply of Fallopian tube:

Arterial supply: Medial 2/3rd by Uterine artery and lateral 1/3rd by Ovarian artery.

Venous drainage: Drains into the pampiniform plexus of the ovary and into the uterine veins.

Lymphatic drainage of Fallopian tube: Into aortic and para-aortic lymph nodes.

Nerve Supply of Fallopian tube:

Sympathetic from ovarian and superior hypogastric plexus and parasympathetic from vagus.

Development of Oviduct:

Mucosa: From cranial vertical and middle horizontal part of the para-mesonephric duct.

Muscle and serous coat: From surrounding mesenchyma.

Functions of Fallopian Tube:

• Transport of sperm and ovum.
• Site of fertilization.
• Helps in development, survival and transport of zygo

Some pathological conditions of Fallopian tube:

A. Infection: Salpingitis

B. Neoplasm

• Benign: Fibroma, Leiomyoma, Haemangioma, Adenomatoid tumour, Polyp
• Malignant: Primarily Choriocarcinoma, Sarcoma, Carcinoma and secondary from ovary, uterus or large intestine.