Physiopathology of endometrial bleeding disturbances in progestin only contraceptives users
ESC Congress Library. Lavin P. May 4, 2016; 126977; A-151
Prof. Dr. Pablo Lavin
Prof. Dr. Pablo Lavin
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Abstract
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1. Objectives: Describe the changes in endometrial growth and structure under the influence of progestin only contraceptives that may lead in some of its users to a subsequential endometrial spotting, prolonged or irregular bleeding.

2. Method: literature review

3. Results: the uterine lining of reproductive-age women, the endometrium, has a single layer of columnar epithelium resting on a layer of connective tissue known as stroma. Stromal tissue is traversed from the surface to the basal layer by the uterine glands and blood supply structures, the spiral arteries. Two layers, known as basal and functional, can be normally distinguished in the endometrium, being the functional layer the one that is shed during menstruation. Menstruation is determined by the orderly sequential liberation of the ovarian sex hormones, during the ovulatory process. Described as an 'inflammatory process' that includes the presence of leukocyte types and immune cells (uterine natural killer cells, macrophages, mast cells, neutrophils, dendritic cells and Tregs), a range of different inflammatory  mediators, proteolytic enzymes, eicosanoids, and growing factors (tissue and vascular).

Since its inception, hormonal contraceptive have disrupted this process by completely or partially blocking the 'hypothalamus-pituitary-ovary' axis in its users, and also by mainly altering the order of the exogenous 'ovary like' hormones that are used, estrogens and progestins.

Intent to keep the natural 'estrogen-progesterone' sequence was made with the 'sequential' contraceptive cycles that are no longer in use. Then, it should be no surprise that the endometrium under the influence of the presently used contraceptive regimens, combined or progestogen only, whose circulating hormone levels differ in order of magnitudes and in its sequence with the natural cycle, should grow differently than the physiological endometrium of the 'menstrual cycle', endometrial morphology is altered. This is even more different with the progestin only regimens, giving a completely different structure to the endometrium layers and its vasculature. This is to say, different cellular structure arrangement because of a different balance of growing factors and also a range of disturbances in endometrial immune cell numbers, distributions and functions. Endothelial growth factors are also differentially affected by the different exogenous hormones resulting in spotting, leaking and fragile blood vessels because of its different layer conformation.

4. Conclusions: bleeding disturbances in hormonal contraceptive user is something that should be expected because of the effect of the exogenous hormones on the endometrial growth and its vasculature, and the inconsistency of a complete blockage of the follicle growth.

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