Menstrual abnormalities (AUB, amenorrhea)

Question 1

Define dysmenorrhea and the difference between primary and secondary.

Answer 1

Recurrent painful menstruation.

Primary = occurs in the absence of pathophysiology.

Secondary = Related to underlying pelvic pathology. (endometriosis, PID, uterine fibroids, ovarian cysts etc.).

Question 2

Describe the role of prostaglandins in dysmenorrhea.

Answer 2

Prsostaglandins released by the endometrium to stimulate uterine contractions which help with sloughing. In primary dysmenorrhea, you have excessive production of endometrial prostaglandins in first 28 hours of menstruation.

Prostaglandin (and derivatives) increase contractility and cause vasoconstriction.

Question 3

How do PMS (premenstrual syndrome) and dysmenorrhea differ?

Answer 3

PMS is generally related to breast tenderness and abdominal bloating rather then a lower abdominal cramping pain.

Question 4

Define amenorrhea

Answer 4

The absence of menstruation in females of reproductive age.

Question 5

What is primary amenorrhea?

Answer 5

The failure of menarche (onset of menstruation) by 16 caused by genetic or anatomic abnormalities.

Question 6

What is secondary amenorrhea?

Answer 6

The cessation of previous menses for more than 6 months.

Question 7

What is Anovulation?

Answer 7

The lack of ovulation.

Question 8

What is oligomenorrhea?

Answer 8

Infrequent menstrual bleeding = fewer than 9 cycles per year or a cylce longer than 35 days. Oligomenorrhea is usually an anovulatory bleeding pattern.

Question 9

How is polycystic ovarian syndrome characterized?

Answer 9

It can be a cause of secondary amenorrhea.

PCOS is characterized by ovulatory dysfunction and hyperadrogenism. In involves an increase in the activity of the pathways involved in androgen synthesis by the ovaries.

Increase activity thought to be one of the following:
- functional ovarian hyperandrogenism
- LH excess
- insulin-resistant hyperinsulinemia

Question 10

How does normal regulation of ovarian androgen production occur.

Answer 10

Theca cells have LH receptors. LH binding stimulates androgen production.
Granulosa cells have FSH receptors. When FSH binds, aromatase is activated to convert androgen to estradiol.

Question 11

What are the effects of excess androgens?

Answer 11

Cutaneous = acne, hirsutism, alopecia

Ovulatory =

Question 12

What role does insulin resistant hyperinsulinemia play in PCOS?

Answer 12

Elevated insulin levels promote release of GnRH. Increased pulse rates stimulate increased LH release
LH stimulates androgen production in theca cells causing hyperandrogenism
Elevatine insulin also decreases sex hormone causing an increase in testosterone which inhibits follicle development
stimulates fat storage which contributes to weight gain and obesity.

Question 13

How do the cysts in PCOS form?

Answer 13

High androgen levels cause:
1) growth of a number of small follicles
2) premature lutenization of follicles

= small preantral follicles form but don’t mature further. A dominant follicle fails to form, and ovulation does not occur. The follicles either degenerate or may remain in the ovary forming a cyst. Cysts represent past failed ovulation events.

Question 14

What is abnormal uterine bleeding (AUB)?

Answer 14

defined as any variation from the normal menstrual cycle and includes changes in:
- regularity
- frequency
- duration
- quantity

Question 15

Possible causes of AUB?

Answer 15

PALM-COEIN
Polyps
Adenomyosis
Leimyoma (fibroids)
Malignancy
Coagulopathy
Ovulatory dysfunction
Endometrial disorders
Iatrogenic
Not otherwise classified

Question 16

What are uterine fibroids?

Answer 16

AKA = leiomyomas

benign tumours of the uterus that affect women of reproductive age. They grow from smooth muscle and fibroblasts of the myometrium. Tend to decrease in size after menopause.

Etiology not certain but genetics and hormones thought to play a role.

Question 17

What are the 3 classifications of uterine fibroids?

Answer 17

1. subserosal = from myometrial cells at the serosal surface (bulge out)
2. submucosal = from myometrial cells just below the endothelium (bulge in).
3. Intramural = located in the uterine wall. May enlarge enough to distort the inner our outer layer.

Question 18

What are the possible mechanisms for heavy bleeding with uterine fibroids?

Answer 18

• Fibroid may distort inner lining causing excessive endothelial growth
• abnormalities of the vasculature and impaired hemostasis - fibroids can interfere with uterine contractions that would normally compress and close off vessels in the uterus.

Question 19

Define infertility, primary infertility and secondary infertility.

Answer 19

Infertility = unable to conceive after 12 months of trying with the same partner.

Primary infertility = if the female has never been pregnant and the male has never successfully inseminated, they said are said to have primary infertility.

If a couple are having trouble getting pregnant in a subsequent pregnancy it is secondary infertility.

Question 20

Causes of female infertility?

Answer 20

1) ovulatory factors
2) structural abnormalities affecting the uterus, uterine tubes or ovaries
3) infection

Question 21

What is endometriosis?

Answer 21

A disease in which endometrial tissue that exhibits hormonal responsiveness grows outside the uterus.

Endometriosis lesions are affected by the same ovarian hormones in the same manner as endometrial tissue in the uterus. If blood supply is sufficient, the ectopic endometrial tissue proliferates, breaks down, and bleeds with the normal menstrual cycle.

Question 22

What is the link between endometriosis and infertility?

Answer 22

Not completely clear. Uterine endometrium in women with endometriosis have an overactive response to estrogen and an underactive response to progesterone. This means the endometrium is not prepared for blastocyte implantation.