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Life Cycle > Endometrium > Flashcards

Endometrium Flashcards

1
Q

What factors are increased during the luteal phase of the menstrual cycle?

A

[in the endometrium]

  • inflammatory cells
  • gland hypertrophy
  • increased mucus secretion
  • spiral artery growth
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2
Q

What are the 4 layers of the endometrium?

A
  • compactum: proliferative layer
  • spongiosum: secretory layer
  • basalis: layer will remain intact after menstruation
  • junctional zone: anchor which sits between basalis layer and the myometrium. Contains properties of both endometrium and muscle. some roles proposed in pregnancy and menstrual problems.
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3
Q

What is mechanism underlying menstruation?

A
  • Caused by withdrawal of E2 and P
  • mediated by PGs (which vasoconstriction) and platelet aggregating factor (PAF)

this causes:

  • spiral artery vasoconstriction
  • spiral artery relaxation
  • PGs cause vasoconstriction of end-arteries in the endometrium - there is no alternative blood supply to these areas so this causes ischaemia
  • ischaemia and tissue damage
  • shedding of functional endometrium
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4
Q

What is the functional endometrium?

A

these are the layers that are lost during menstruation

=> compactium and spongiosum layers

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5
Q

What are the 2 general types of prostaglandins?

A

VASOCONSTRICTORY
promote platelets clotting (pro-coagulable)
PG-F2a and PG-Tx

VASODILATORY
reduces platelet binding to the endothelium
(pro-bleeding)
PG-E and PG-I

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6
Q

What are the general functions of prostaglandins?

A
  • inflammatory mediators
  • vasodilation
  • vasoconstriction
  • sensitise pain receptors (all classes of PGs)
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7
Q

What inflammatory mediators are released during menstruation?

A
  • PGs
  • IL-8, IL-13, IL-16
  • TNF
  • PAF
  • Matrix metalloproteinases (MMPs)
  • coagulation/fibrinolysis
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8
Q

What must occur for “normal menstruation?”

A

correct balance and regulation of inflammation, coagulation and fibrinolysis in the endometrium

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9
Q

What clinical problems can occur in association with menstruation?

A

[anything different to usual baseline pattern]

  • menorrhagia: excessive bleeding
  • polymenorrhoea; bleeding too often
  • Inter-Menstrual bleeding (IMB)
  • post-coital bleeding (PCB)
  • Chaotic bleeding: constant and not regulated at all
  • functional abnormality: endometrium is normal but something is not working functionally
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10
Q

What are pathological causes of abnormal vaginal bleeding?

A
  • fibroids (submucosal)
  • adenomyosis
  • endometrial pathology
  • cervical pathology
  • pregnancy
  • cervical ectropion
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11
Q

What kinds of endometrial pathology can cause abnormal vaginal bleeding?

A

benign adenomas or polyps
hyperplasias
carcinoma

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12
Q

What kind of cervical pathology can cause abnormal vaginal bleeding?

A

polyps
carcinoma
infective: chlamydia

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13
Q

What are cervical ectropion caused by?

A

oestrogen expo

can result in abnormal vaginal bleeding

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14
Q

What is adenomyosis?

A

pockets of endometrium in the myometrium.

often caused painful, heavy periods

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15
Q

What are submucous fibroids?

A

fibroids: benign myometrium mass
submucous: fibroid poking into uterine cavity (can affect bleeding)

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16
Q

What is DUB?

A

dysregulated uterine bleeding
(= AUB)

Dx of exclusion (no identified organic cause of bleeding issues)

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17
Q

What is the significance of submucous fibroids?

A

associated with 3x increased risk of abnormal peri-menopausal bleeding

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18
Q

What is the significance of polyps?

A

more frequent in women with menstrual disorders or abnormal bleeding on HRT

19
Q

What needs to be considered when dealing with abnormal bleeding?

A
  • exclude pregnancy
  • exclude cervical pathology
  • exclude focal intracavity pathology (polyps, submucous fibroids)
  • consider endometrial pathology for >40yo

[use the least invasive method to achieve this]

20
Q

What are the important points in the history to consider in abnormal vaginal bleeding?

A
  • last menstrual period
  • regular or irregular periods
  • inter-period bleeding
  • heavy clots? flooding?
  • post-coital bleeding?
  • pain
  • medication
  • smoking history
  • smear
  • past operations
  • contraception: is family complete?

N.B. progesterone contraception can cause irregular bleeding

21
Q

What points in examination are important to consider for abnormal vaginal bleeding?

A
  • BMI
  • Abdo: distension, scars, pain, masses
  • Bimanual: uterine size, adnexal masses, pain
  • cervix: polyps, suspect lesions
22
Q

Why is BMI an important consideration for abnormal uterine/vaginal bleeding?

A

if overweight then will be hyper-oestrogenic

peripheral fat depots make oestrogen

23
Q

What investigations should be done for abnormal vaginal/uterine bleeding?

A
  • pregnancy test (if appropriate)
  • Haemaglobin (if heavy bleeding)
  • swabs: endocervical (for chlamydia)
  • transvaginal USS
  • endometrial sampling (biopsy)
  • hysteroscopy (in-patient or OPD)
24
Q

What kind of anaemia is most common with heavy uterine bleeding?

A

iron-deficiency anaemia

25
Q

What is transvaginal sonography (TVS)?

A
  • can assess relationships of fibroids to the cavity
  • high detection rate for polyps
  • assess function: anovulatory cycles
  • assess tubal and ovarian pathology
  • well-accepted by patients
  • cheap with few complications
26
Q

What are the limitations of transvaginal sonography (TVS)?

A

good for focal pathology

not good for predicting endometrial pathology: biopsy still needed for many cases

periovulatory or post-menstrual endometrium: difficult to gauge endometrial thickness

27
Q

What is the use of hydrosonography?

A

used in conjunction with TVS

allows separation of 2 layers to see in between

28
Q

What is the normal endometrial thickness (ET) in pre-menopausal women?

A

6mm post-menstrual

12mm (max.) anytime in cycle

[arbitrary values]

29
Q

When is a hysteroscopy indicated?

A
  • if TVS is abnormal
  • no response to medical therapy
  • multiple risk factors for endometrial pathology
30
Q

What are the risk factors for submucous fibroids?

A
  • obesity
  • nulliparity
  • early menarche/late menopause
  • hypertension
  • DM
  • anovulation e.g. PCOS
  • FHx breast/endometrual/colonic Ca (CA-125 Ag)
31
Q

What is the classical presentation for endometrial Ca or PCOS?

A

obesity
HT, DM
peri-menarche
[Metabolic X syndrome]

32
Q

What is the main cause of endometrial hyperplasia?

A

unopposed oestrogen (E2) with no progesterone e.g. anovulatory

can Rx with progesterone to balance

33
Q

What are the 3 types of endometrial hyperplasia?

A
  • simple (benign)
  • atypical (aka dysplastic, not benign and on its way to malignant)
  • carcinoma
34
Q

What are the Rx for polyps?

A

SURGERY
transcervical removal of polyps (TCRP)
vs
polypectomy

TCRP is a more definitive removal, less chance of polyp returning)

35
Q

What are the Rx for fibroids?

A

MEDICAL
Mirena coil IUS

SURGERY
transcervical removal of fibroids (TCRF)
Myomectomy (requires abdo approach)
Hysterectomy (total/subtotal abdo, vaginal)

36
Q

What is a contraindication for Mirena IUS?

A

abnormal uterine cavity

e.g. multiple uterine fibroids

37
Q

What are the consideration for Rx for DUB?

A

does she want or need Rx?
does she need contraception/pregnancy?
how much is it affecting QoL?
is she physically compromised?

38
Q

What are the Rx options for DUB?

A
  • nothing
  • Medical: hormonal vs. non-hormonal
  • Surgery
39
Q

What are the non-hormonal Rx options for DUB?

A

ANTI-FIBRINOLYTIC
40-50% reduction in blood loss
e.g. TXA

MEFENAMIC ACID
30% reduction in blood loss

40
Q

What are the hormonal Rx options for DUB?

A

COCP
20-30% reduction in blood loss

MIRENA IUS
90% reduction

[progestagens are not beneficial for blood loss, used to control cycle length in anovulatory DUB]

41
Q

How does mefenamic acid work to control DUB?

A

menorrhagia: more dilatory PGs present

Mefenamic acid shifts the PGs to reduce the vasodilatory PGs

=> specific effect on bleeding loss and pain Mx in uterus

42
Q

What are the surgical options for Rx DUB?

A
  • endometrial resection/ablation
  • hysterectomy (vaginal/abdominal, more commonly laproscopic)
  • oophorectomy
43
Q

What is the most common surgical Rx for DUB?

A

radio frequency ablation (produced heat) of endometrium

-permanent frying of endometrial tissue

44
Q

What is Ponstan?

A

trade name for Mefenamic acid

Life Cycle (29 decks)

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